Surgery

New born with anorectal malformation

Anorectal Malformations

• Isolate the baby,
• Maintain temperature,
• Insert nasogastric tube to rule out esophageal atresia and decompress stomach,
• Reassure and counsell parents .
• Explain prognosis.

Pharmacological

It is required in all the cases that are to be undertaken for surgery in the form of definitive procedure or preliminary colostomy.

1. Intravenous fluids 10% Dextrose 60 ml/kg per day (first 48 hours) and Isolyte P 100 ml/kg body weight thereafter till required.
2. Inj. Vitamin K 1 mg IM stat
3. Inj. Ampicillin 50-100 mg/kg in 4 divided doses for 7 days.
4. Inj. Metronidazole 7.5 mg/kg per day in 3 divided doses for 3 days.

Surgical treatment (Best carried out by a qualified paediatric surgeon)

Figure 1 & 2 depict exmamination and management of anorectal anomalies in male and female new borns.Transfer newborns to such centers for performing the definitive surgery. However, colostomy can be performed at places where expertise for doing definitive procedure is not available.

Anovestibular fistula can be managed by cut back procedure at a peripheral center as initial procedure. Anal stenosis can be managed by anal dilatation.
If unsure, it is safe to perform a sigmoid colostomy before referring the patient to a tertiary care center.

Parent education

• Reassure the parents and explain the nature of anomaly and also explain that the child would require multiple surgical procedures to correct the malformation.
• Teach the parents the care of the colostomy – not leaving it open, cleaning around it with soft cotton cloth soaked in water, not rubbing over the colostomy to prevent bleeding, management of prolapsed colostomy and follow-up schedule.

References

1. Anorectal Malformations. In: Paediatric Surgery. O’Neill Jr., Rowe MI, Grosfeld JL et al (eds), 5th Edition, 1998, St. Louis.

New born with anorectal malformation

Figure 1. Male

Figure 2. Female

Undescended Testis

1. If the newborn child is seen with unilateral undescended testis, follow up the patient at intervals to see the descent. If testis fails to descend by the age of 12 months, orchiopexy is advised. If seen after first birthday the operation of orchiopexy should be done before the age of two years. The operation entails mobilizing the testis and cord structures and fixing it in the subdartos pouch in the scrotum with unabsorbable sutures.
2. If the newborn child has bilateral undescended testes with hypospadias, it should be investigated for intersex disorder.
3. If a child has undescended testis with clinically visible hernia, orchiopexy can be done at an earlier age along with herniotomy.

Patient education

• The parents should be informed about the anomaly if detected at birth and advised to monitor the descent of testis and to get it operated by the age of 1 year.

References

Undescended Testis, Torsion and Varicocele. In: Paediatric Surgery, O’Neill Jr, Rowe MI, Grosfeld JL et al (eds), 5th Edition, 1998, Mosby, St. Louis.

Paediatric surgical conditions-Spina Bifida

1. If the lesion is detected on antenatal ultrasound, parent counseling should be done after investigations for other associated congenital malformations.
2. If the parents opt for continuation of pregnancy, they should be referred to a center where facilities of paediatric surgeons or neurosurgeon are available.
3. If a newborn baby is seen with a defect on the back, baby should be taken for immediate surgery after relevant investigation at a center where expert surgical expertise and operating facilities for neonatal surgery are available. At the peripheral center management would include:

• Isolation of the newborn and prevention of hypothermia.
• Care of the lesion and back to prevent desiccation and trauma.
• Nursing in a prone position.
• Intravenous fluids -10% Dextrose 60 ml/kg/day for the first 48 hours of life.
• Inj. Ampicillin (500 mg/vial) 100 mg/kg in 4 divided doses.
• Transfer the baby to a tertiary care center.

Parent education

• If diagnosed in antenatal period, parents are counselled and investigated for severity of lesion and possible outcome.
• Abortion may be advised if associated anomalies are noted in the foetus.

References

1. Management of Spina Bifida, Hydrocephalus, Central Nervous System Infections and Intractable Epilepsy. In: Paediatric Surgery, O’Neill Jr, Rowe MI, Grosfeld JL et al (eds), 5th Edition, 1998, Mosby, St. Louis.

Haemorrhoids

• Avoid constipation and use laxative if required.
• Use high fiber diet that produces high roughage.
• Sitz bath to reduce pain and spasm.
• Haemorrhoids that prolapse should be reposed gently and not forced back.
• Take treatment for any disease that promotes straining at micturition like benign hypertrophy of prostate.

References

Benign Diseases of the Anorectum. In: Maingot’s Abdominal Operations. Zinner MJ, Schwatz SI, Ellis H (eds), 10th Edition, 1987, Prentice Hall International, pp 1437-1444.

Fistula-In-Ano

1. Cap. Ampicillin 500 mg every 6 hours.
2. Tab. Metronidazole 400 mg every 8 hours.
3. Bulk laxative to relieve and avoid constipation.
   Definitive treatment is fistulotomy (laying open of the fistula tract), fistulectomy (excision of the fistula tract) and use of Seton. Secondary fistula needs treatment of primary disease. High level fistula may need proximal colostomy for treatment.

Patient education

• Do not take treatment for anal disorders like abscess and fistula from unqualified persons.
• Avoid constipation and take bulk laxatives.
• Maintain local hygiene.

Reference

Benign Diseases of the Anorectum. In: Maingol’s Abdominal Operations, Zinner MJ, Schwatz SI, Ellis H (eds), 10th Edition, 1997, Prentice Hall International. London, pp. 1437-1454.

Fissure-In-Ano

• Sitz bath- sitting in a tub containing luke warm water with potassium permanganate to provide relief from spasm and pain.
• Local hygiene.
• High fiber diet to prevent constipation.

• 2% Glycerine trinitrate as an ointment for local application.
• Manual dilatation of the anal sphincters-Lord’s procedure.

Surgical

• Lateral anal sphincterotomy.
• Dorsal fissurectomy and sphincterotomy.
  Complication of surgical treatment could include mild incontinence and prolonged healing time.

Patient education

• Local care of the region and sitz bath should be regularly taken.
• Avoid constipation by the use of high fiber diet and use of purgatives.

Scrotal Swellings

1. Cap. Doxycycline 100 mg once daily for 8- 10 days. It may be changed according to urine culture and sensitivity.
2. Analgesic and antipyretics may be required.

C. Torsion Of Testis

Torsion of testis is most common between ages of 10- 25 years though it may occur at any age.

Treatment (Immediately refer to a higher centre)

Treatment of torsion of testis requires immediate correction by surgical exploration through scrotal incision, untwisting of the cord and orchiopexy.

It is important to fix the opposite testis at the same time. It is of paramount importance not to delay the exploration even if diagnosis is doubtful or for the want of special investigations. Any undue delay can lead to gangrene of the testis.

Patient education

• Any scrotal swelling should be brought to notice of your doctor.
• Any sudden onset swelling of the testis merits immediate attention of the surgeon and delay in diagnosis or treatment even for few hours can be harmful.

References

1. Disorders of the Testis, Scrotum & Spermatic Cord. In: Smiths General Urology, Tanagho EA, McAninch JW. (eds), 15th Edition, 2000, McGraw Hill Company Inc., New York, pp 6784-693.

Inguinal Hernia

• Reduce weight and quit smoking before surgery.
• Treatment of any predisposing factors like chronic cough, prostatic enlargement and constipation is necessary.
• The surgery should not be delayed since complications of hernia are frequent and can be serious.
• After surgery, avoid lifting heavy weights, cycling etc. for three months.

References

Hernias. In: Maingot’s Abdominal Operations, Zinner MJ, Schwartz SI, Ellis H (eds), 10th Edition, 1997, Prentice Hall International, pp 497-580.

Retention Of Urine

1. Mechanical causes of retention are: posterior urethral valves, foreign bodies, tumours, blood clot and stones, phimosis, paraphimosis, trauma (rupture of urethra or bladder), urethral stricture, urethritis, meatal ulcer, tumours, prostatic enlargement-benign or malignant, retroverted gravid uterus, fibroid, ovarian cyst, faecal impaction.
2. Neurogenic- Postoperative retention, neurogenic bladder, spinal cord injuries, hysteria, drugs- anticholinergics, antihistaminics, smooth muscle relaxants.

Treatment

1. General measures include sedation, adequate hydration and antibiotics if sepsis is present.
2. If there is history of trauma, urethral injury should be ruled out before attempting catheterization.
3. If the urethra is patent, a catheter is passed in to the bladder under strict aseptic precautions and is connected to a sterile closed collecting system. The catheter is chosen according to the size of the external meatus. In cases of acute retention, single catheterization is adequate or an indwelling self-retaining catheter is inserted if deemed necessary.
4. If urethral pathology is present or there is inability to pass the catheter, a suprapubic puncture or cystostomy is performed to relieve the retention.
5. In case of chronic retention, decompression should be performed intermittently (300-400 ml volume) to avoid haematuria that can occur after sudden decompression.
6. The patient should be kept under observation after admission for investigation to elucidate the cause of retention. The investigations include urine examination, renal functions, plain and contrast radiological studies, ultrasound, CT scan or MRI. Urodynamic studies are required to diagnose neurogenic bladder. Cystoscopy can help to diagnose and treat many conditions of the urethra and urinary bladder.
7. Definitive treatment of the aetiology is done after proper investigations.

Pharmacological

1. Tab. Cotrimoxazole (960 mg) 2 times a day
   Or
   Tab. Norfloxacin 400 mg 2 times a day for 5-7 days. This may be changed according to urine culture and sensitivity reports.

Patient education

• Explain catheter care-measures – tip of the urethra should be cleaned with antiseptic solution regularly.
• Watch for blood in urine.

References

1. The Urinary bladder. In: Bailey & Loves Short Practice of Surgery, Russel RCG, Williams NS, Bulstrode CJK. Arnold (eds), 23rd Edition, 2001, pp 1204-1208.

Appendicitis

1. Intravenous fluids to maintain hydration. Requirement of fluids would be more if the patient has peritonitis & septicaemia.
2. Inj. Ciprofloxacin infusion (100 mg/50 mg) 100 ml twice a day for 5 days.
3. Inj. Gentamicin (40 mg/ml), 80 mg IV 8 hourly.
   Or
   Inj. Amikacin (500 mg/2 ml), 2 ml IV twice a day.
4. Inj. Metronidazole infusion (500 mg/100 ml) 100 ml IV 8 hourly.
5. Inj. Diclofenac sodium (25 mg/ml) 50 ml IM SOS.
   (CAUTION: Purgation & enema are contraindicated)
   Pain subsides first, followed by relaxation of the abdomen and control of fever. Tenderness disappears later. Polymorphonuclear leucocytosis tends to settle down. Failure of signs & symptoms to subside or the appearance of new signs & symptoms during expectant treatment, calls for surgical intervention

• Oral feeding is started when abdomen is soft, the patient has passed flatus/stools and bowel sounds have appeared. Start with liquids, gradually permitting semi solid & solid diet over a period of 2-3 days.
• Antibiotics should continue for 5 days or more if the condition demands.
  Initially they are given by parenteral route and later switched to oral route when the patient starts tolerating semi solid diet.
• Patient is discharged usually between 3rd & 5th postoperative day, when he is comfortable, ambulatory, tolerating semi solid or solid food, afebrile and has a healthy wound.
• Sutures are removed around 7th postoperative day.

• Normal routine physical work can be permitted in 10-15 days (5-7 days after laparoscopic appendicectomy).
• Moderate physical work is permitted after 4-6 weeks (2 weeks after laparoscopic appendicectomy).
• Heavy physical work is permitted after 2-3 months (4-6 weeks after laparoscopic appendicectomy).

Appendix and Appendicectomy. In: Maingot’s Abdominal Operations, Zinner MJ, Schwartz SI, Ellis H (eds), 10th Edition, 1977, Prentice Hall International. pp 1191-228.

Cholelithiasis

1. Inj. Ciprofloxacin (Infusion 100 mg/50 ml) 100 ml IV twice a day.
2. Inj. Gentamicin (40 mg/ml) 2 ml IV 8 hourly.
   Or
   1. Inj. Ampicillin (500 mg/ml) 1 ml IV 6 hourly.
   2. Inj. Cloxacillin (500 mg/ml) 1 ml IV 6 hourly.
   Or
   1. Inj. Ciprofloxacin (Infusion (100 mg/50 ml) 100 ml IV twice a day.
   2. Inj. Amikacin (500 mg/2 ml) 2 ml twice a day.
3. In case anaerobic bacterial infection is suspected or anticipated, give Inj. Metronidazole (500 mg/100 ml) 100 ml IV 8 hourly.
4. Inj. Diclofenac sodium (25 mg/ml) 2 -3 ml IM SOS or 6 hourly.
   Or
   Inj. Pentazocine lactate (30 mg/ml) 1 ml IM SOS.
5. Inj. Hyoscine butylbromide (20 mg/ml) 1 ml IV SOS.
6. In patients having obstructive jaundice, add Inj. Vitamin K (10 mg/ml) 1 ml IM once or twice a day till prothrombin time reaches to a satisfactory level.
   Antibiotics are usually stopped after 5-7 days unless the patient has evidence of persistent infection or has indwelling tube (e.g., T-tube).

• To avoid fatty & fried meals for 3 months.
• Although ambulation is encouraged as early as possible, heavy physical exertion should be avoided for 2 weeks (after laparoscopic cholecystectomy) and for 3 months after conventional cholecystectomy.
• If T-tube has been placed, it should be removed after 2-3 weeks, after ensuring that the CBD is patent, non dilated and there is free flow of contrast into the duodenum.

Cholelithiasis and Cholecystectomy. In: Maingot’s Abdominal Operations, Zinner MJ, Schwartz SI, Ellis H (eds), 10th Edition, 1977, Prentice Hall International, pp 1717-1738.

Acute Abdomen

1. Inflammation of peritoneum due to bacterial or chemical contamination. Perforation of appendix or bowel, ulcer, pancreatitis or pelvic inflammatory disease.
2. Mechanical obstruction of hollow viscera-intestinal obstruction, ureteric obstruction due to stone or other causes, obstruction of the biliary tree.
3. Vascular disturbances – vascular rupture, embolism or thrombosis, torsion of pedicle.
4. Abdominal wall injury or infection in the muscles. Referred pain in case of pneumonia, angina, spine-radiculitis and torsion of testis.

Metabolic causes

Insect bite, lead poisoning, uremia, diabetic ketoacidosis, porphyria and other allergic causes.

Neurogenic causes

1. Organic- Tabes dorsalis, Herpes zoster, neuralgia.
2. Functional.

Approach to the patient with acute abdomen

1. In view of the variety of causes, it is absolutely essential to elicit an orderly detailed history about the nature of pain and perform a sequential examination. Narcotics or analgesics should be withheld till the diagnosis is made.
2. A proper history can provide more valuable information than the investigations. The features of the history that must be elicited are site, time and nature of onset, severity, nature of pain, progression, duration, relieving factors, exacerbating factors and radiation. History of GI complaints like vomiting, constipation, haematemesis and melena and urinary complaints should be obtained.
3. Examination of the patient with respect to facies, posture in the bed, respiration can help in localizing the cause and nature of pain. The abdominal examination should be thorough but extremely gentle starting from the nontender area. Points to be noted are area of maximum tenderness, guarding, rebound tenderness, bowel sounds, obliteration of liver dullness and presence of any associated mass or free fluid in the abdomen.
4. It is important not to miss examination of supraclavicular lymphnodes, hernial orifices, peripheral pulsations, genitalia, bowel sounds and rectal and/or vaginal examination.
5. Laboratory investigations depend upon the suspected cause of pain and include haemogram, kidney function tests, liver function tests, serum or urinary amylase and lipase, blood sugar and urinalysis. Special analysis like serum lead estimations may be needed if deemed necessary.
6. Radiological investigations include plain radiographs of abdomensupine and erect and chest. In a sick patient, lateral decubitus X-ray may provide the same information. Ultrasound, computed tomography and special radiological investigations may be done as and when required.
7. Invasive procedures like endoscopy and laparoscopy are done only if indicated.
8. It may be necessary to rush the patient to operation room if there is suggestion of intra-abdominal haemorrhage along with pain. Any delay for history, examination and investigations can cause more harm to the patient.
9. There may be occasions when the cause of the pain cannot be determined on the basis of clinical examination and investigations. Under such circumstances, it is prudent to provide pain relief to the patient and keep him under observation to watch for development of new signs or symptoms.

Treatment

Treatment of acute abdomen depends upon the cause of pain. In case of medical causes of pain, the offending cause is removed or treated appropriately.

Pharmacological

This depends upon the aetiology of pain.

• In soft tissue lesions or trauma NSAIDs are prescribed.
• In obstruction or colicky pain due to spasm, Tab. Dicyclomine SOS.
• Initially, injectable administration may be needed for severe pain and later it may be switched to oral route.
• Narcotics may be given in case of severe pain.
• Antibiotics are given for inflammatory causes of pain.

Surgical

Any acute surgical cause of acute abdomen like perforation peritonitis, appendicitis, perforation of ulcer etc. should be treated immediately and appropriately.

Patient education

1. Do not administer analgesics for acute abdomen on your own. This may delay treatment of surgical cause.
2. Enema should not be self-administered for constipation without advise of the treating physician/surgeon.
3. Narcotic analgesics should be taken for minimum period as long term intake may lead to addiction.

References

Abdominal Pain. In: Harrison’s Principles of Internal Medicine, Braunwald E., Fauci AS, Kasper DL et al (eds), 15th Edition, 2000, McGraw Hill Company Inc., New York, pp 67-70.

Dysphagia

1. Intraluminal (e.g. foreign body)
2. Intramural (e.g. achalasia, oesophagitis, oesophageal strictures, Plummer-Vinson syndrome, pharyngeal pouch, benign neoplasm, malignant neoplasm) or
3. Extra luminal (e.g. retrosternal goitre, mediastinal tumor, mediastinal lymphadenopathy, aortic aneurysm, hiatus hernia).

Investigations

• Barium swallow to evaluate cause, site & extent of the lesion and the state of the oesophagus above & below the lesion; upper GI endoscopy for direct vision evaluation and for taking tissue for histopathological examination wherever indicated.
• Abdominal ultrasound, chest x- ray and other routine investigations.
• CT scan and endoscopy ultrasound to be considered in tertiary care centres, wherever indicated; and oesophageal manometry, pH studies and evaluation for H. pylori to be considered in tertiary care centres, wherever indicated.

Treatment

Definitive treatment depends on the cause and its extent.

Nonpharmacological

• Diet restricted to liquids or semi solids depending upon extent of dysphagia.
• Psychotherapy if the patient is depressed or demoralized.

Pharmacological

Gel Magnesium hydroxide + Aluminium hydroxide + Activated
Dimethicone (250 mg + 250 mg + 50 mg/ml) 20 ml 6 hourly.
Or
Tab. Ranitidine 150 mg 2 times a day.

References

Dysphagia. In: Harrison’s Principles of Internal Medicine, Braunwald E, Fauci AS, Kasper DL, Hausen SL et al (eds), Vol. 1, 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 233-235.

Breast Abscess

1. Tab. Erythromycin 500 mg 3 times a day for 7 days.
2. Tab. Metronidazole 400 mg 3 times a day for 7 days.
3. Tab. Ibuprofen 400 mg as and when required.

1. Antibiotics as above.
2. Incision and drainage of pus through thinned skin over the abscess (Large abscesses require operation under intercostal block or general anaesthesia).
3. Daily dressing.
   In some cases suppress lactation with hormones if the mother finds
   breast feeding too painful.

Patient education

• To maintain good hygiene and to continue breast feeding from both the sides unless it is a large abscess and very painful.
• Advise on timely weaning of the infant.

References

Abscesses in Special Sites. In: Hamilton Bailey’s Emergency Surgery, Ellis BW, Paterson-Brown S. Arnold (eds), 13th Edition, 2000, London pp 165-166.

Thyroid Swelling

Thyroid swelling forms one of the most important differential for swelling in front of the neck. The differential diagnosis of thyroid swelling are benign goiter, intrathyroid cysts, thyroiditis, benign and malignant tumours. Simple goitre is enlarged thyroid gland and occurs commonly around puberty in girls due to iodine deficiency. Malignancy should be suspected in case of extreme of age, male sex, rapidly growing swelling, persisting pain, dysphagia, recurrent laryngeal nerve palsy, hardness and fixity of the thyroid gland and presence of one or more palpable neck nodes. Fine needle aspiration cytology, isotope scan and ultrasonography are helpful in differentiating the causes of thyroid swelling.

Treatment

Simple diffuse hyperplastic goitre is preventable by using iodised salt.

Treatment with L-thyroxine can reverse the swelling at the stage. Simple nodular goitre is treated by subtotal thyroidectomy (for details see Figure 1).

Figure1. Management plan for thyroid nodule

Thyroidectomy

Preoperative care

Preoperative antibiotic prophylaxis (Inj. Ampicillin 1 g IV 30 min before operation) is given to the patient. Preoperative thyroidectomy indirect laryngoscopy (IDL) is performed to identify compensated or unsuspected recurrent laryngeal nerve palsy. Before operation, thyrotoxic patient should be made euthyroid with antithyroid drugs (carbimazole 0-15 mg 4 times a day and propranolol 20 mg 3 times a day). Fully discuss the potential complications with the patients – mentioning the risk to parathyroid gland and recurrent laryngeal nerve.

Postoperative care

Place patient in a slightly propped up position. Carefully observe for respiratory insufficiency, haemorrhage from the wound, irritability to the facial nerve and carpopedal spasm (parathyroid injury). Monitor drain output daily and remove if 24 hours output becomes lesser than 10 ml. Check wound site for infection and suture removed on the 5th day.

Complications

The most immediate life threatening complication is haemorrhage under deep cervical fascia, which can lead to acute asphyxia. Management include reopening of the suture line, drain the haematoma and reexploration for control of bleeders. Damage to recurrent laryngeal nerve can lead to respiratory distress (bilateral recurrent laryngeal nerve) and hoarseness of voice. Parathyroid damage leads to hypocalcaemia.
Symptomatic hypocalcaemia (positive Chovstek’s or Trousseau’s sign) or corrected serum calcium level < 8 g/dl is treated with 10% calcium gluconate intravenously. If hypocalcaemia persist, oral calcium supplement and synthetic Vitamin D is necessary.
Late complication includes recurrent thyrotoxicosis (Grave’s disease), hypothyroidism, recurrence of malignancy at the local site or in the lymph nodes in the neck.

Radioiodine therapy is indicated in follicular, papillary and mixed carcinoma. Following total thyroidectomy, a total body radioactive isotope scan should be arranged four weeks after the operation. During this period L-thyroxine therapy should be withheld. If radioactive scan shows residual thyroid tissue or metastatic deposit then further dose of radioiodine should be given to ablate these. Following isotope scan, high dose L-thyroxin (0.2-0.3 mg) should be started and continued for life. Radioactive iodine has no role in residual/metastatic medullary carcinoma. Treatment approach to Hurthle cell neoplasm is similar to follicular neoplasm.

Follow up

Patients should be followed at three monthly intervals for the initial 2 years and 6 monthly for next three years and then at yearly interval for life. On each follow up visit patient should be examined for any local or nodal recurrence in the neck, a chest X-ray should be done to exclude pulmonary deposit and clinical features of thyroid toxicity noted and dose of L-thyroxin regulated.

References

1. The Thyroid Gland. In: The New Aid’s Companion in Surgical Studies. Burnand KG, Young AE (eds), 2nd Edition, 1998, Churchill Livingstone, London pp 459-485.

Cervical Lymphadenopathy

1. In case of acute suppurative lymphadenopathy secondary to any bacterial focus of infection in the drainage area.
   Cap. Cephalexin 250-500 mg every 6 hours for 7 days.
   Or
   Cap. Amoxicillin 250-500 mg every 8 hours for 7 days.
   If lymph nodes persists, perform fine needle aspiration cytology (FNAC) and treat accordingly. If FNAC is nonconclusive take a biopsy from the enlarged lymph
   node and treat accordingly.
2. In case of chronic lymphadenopathy perform FNAC and treat accordingly. If FNAC is nonconclusive, perform biopsy and treat accordingly.

The Neck. In: The New Aid’s Companion in Surgical Studies, Burnand KG, Young AE, 2nd Edition, 1998, Churchill Livingstone, London pp 451-455.

Varicose Veins

1. Telangiectasia/hyphenwebs (spider veins): intradermal varicose veins that are small and rarely symtomatic.
2. Reticular veins: subcutaneous veins that begin at the tributaries of the trunk veins.
3. Trunk veins: varicose veins of the greater/lesser saphenous system and its named tributaries.

Chronic venous insufficiency

1. Dilated subcutaneous veins.
2. Hyperpigmented/depigmented areas.
3. Open/healed ulcer.

Treatment

Carefully examine the lower limb for sapheno-femoral reflux, varices and perforators in thigh and manifestations of venous insufficiency in calf and foot. Reassurance, the use of elastic compression stockings, injection sclerotherapy or surgical treatment.

Surgical

A recent episode of deep venous thrombosis is a contraindication for operation in the superficial venous system. However, in patients with old deep vein thrombosis (DVT), perforator or obviously varicose long or short saphenous system should be ligated or treated by sclerotherapy. The most definitive approach in the thigh perforators is flush ligation and thigh stripping, with careful attention to groin tributaries. Saphenofemoral ligation alone can be performed under local anaesthesia but the addition of stripping or operation of the sapheno popliteal system warrants spinal/general anaesthesia.

In case of small varices and those where the main long and short saphenous veins and their major tributaries, are competent, injection sclerotherapy with STD (sodium tetradecyl sulphate) is best used in the management of large varicose veins and perforators in the calf. Treatment can be repeated when necessary.

Technique: Place 25G needle into the varices or perforators. Empty the vein and inject 0.5 ml of sclerosant i.e. STD. Compression is applied immediately with compression bandage or stocking.
Or
Ambulatory phlebectomy (avulsion of veins) prevents venous recanalization with recurrence.

Postoperative management

• Compression bandaging immediately following stripping or avulsion of veins. Replace bandages by compression stocking after 2 days.
• Limb elevation and encourage the patient to walk with compression stockings after first change of dressing 48 hours after operation.
• Postoperative pain is controlled with dextropropoxyphene or NSAIDs.

Patient education

• Certain do’s are leg exercise, leg elevation, wear stockings and drinking 4-5 L of fluids in a day.
• Certain don’ts are hot bath, exposure to extreme of temperatures, pregnancy, contraceptive pills and estrogens, long journeys (flight).
• Teach the patient leg exercises-frequent movements of toes and heels, Sarvangasan or Shirshasan, and elevation of foot end of the bed about 6 inches by putting a block of wood or 2 bricks under foot end of bed.
  To avoid prolonged standing or dangling legs down.

References

Venous Disorders. In: Bailey and Love’s Short Practice of Surgery, Russel RCG, Williams NS, Bulstrode CJK. Arnold (eds), 23rd Edition, 20000 London, pp 235-255.

Wound Care

1. Irrigate gently with copious quantities of water or normal saline. Debris and necrotic tissue should be removed without damaging healthy tissue.
2. Healing of acute wound is further facilitated by closure. Alternatively, closure can be delayed for several days to allow infection to clear.

• Encourage daily or twice a day bath, to avoid walking bare foot or with slippers and patient should be encouraged to wear shoes and socks.
• Patients with leg ulcer to reduce standing or excessive walking. In leg ulcer due to chronic venous insufficiency or edema, patients should be advised to wear elastic stockings, elevation of leg and foot end of the bed while asleep along with some leg exercises to activate the calf muscle pump.

Pharmacological

Identify the microorganism and treat accordingly. Tubercular ulcer is treated with antitubercular drug (2HRZE+7HR) for at least 9 months.

Surgical treatment

Surgical debridement in ulcers associated with necrotic tissue or slough. Clean the wound with physiological normal saline or tap water only (antiseptics delay wound healing).

Daily dressing
Gauze adheres to the wound bed and it may remove viable tissue from the wound surface on removal, resulting in delayed wound healing.
Occlusive (moisture retentive) dressings (Hydrocolloid gel) in case of clean and shallow ulcers without any pus discharge or other features of infection. Occlusive dressings have barrier properties that enable to prolong the presence of moisture and wound fluid in the wound bed.
Calcium alginate dressing: For bleeding wounds and wounds with a cavity.
Refer patients with chronic leg ulcer to a vascular surgeons general surgeons or with some experience in peripheral vascular problems for surgical treatment.

Patient education

• To prevent ulcers in future, explain about the care of leg ulcers, wearing socks, shoes and compulsion stocking.
• Good personal hygiene (daily bath) and after the bath the healed scar area should be massaged with an emollient cream such as lanolin or some other oil to keep the scar tissue soft and supple and prevent further breakdown.
• Regular use of calf muscle activating exercises and leg elevation and to avoid prolonged period of standing or sitting with legs down.
• In case of diabetic patients, control of diabetes is necessary.

References

Incisions, Closures & Management of Wound. In: Maingot’s Abdominal Operators. 10th Edition, 1987, Prentice Hall International, pp 395-426.

Post Operative Care

• Preoperative predisposing factors:
  Age, obesity, malnutrition, diabetes and malignancy.
• Operative predisposing factors:
  Duration of surgery, type of operative wound.
  Clean – 1%, clean contaminated – 1-5%, contaminated 5-30%, dirty – more then 30%, poor surgical technique, break of sterilization.
• Postoperative – cross infection in wards.
  Staphylococcus aureus is the most frequently involved organism. Other less common organisms are Enterococci, Pseudomonas, Proteus, E. Coli and Klebsiella.

1. Drainage: Wounds are managed by opening up the incision to provide adequate drainage.
2. Dressing: Daily dressing with Povidone iodide 5% and a wick is placed to prevent pre mature closure of the wound.
3. Analgesics: Tab. Ibuprofen 400 mg 3 times a day till pain is there.
4. Deep Infections: antibiotics are given on the basis of pus culture and sensitivity in addition to drainage of wound.

1. Antibiotics: depending upon sputum culture and sensitivity. Initial treatment can be started with aminoglycoside and antipseudomonas Cehphalosporins.
2. Inj. Ketorolac 30 mg every 6-8 hours IV or IM
   Or
   Inj. Diclofenac 75 mg IM every 6-8 hours.
3. Chest physiotherapy
4. Nebulized bronchodilators: may be used if bronchospasm is present.

Preoperative and Postoperative Management. In: Maingot’s Abdominal Operation , Zinner MJ, Schwartz SI, Ellis H, 10th Edition, 1997, Prentice Hall International, pp 461-478.