#7551 - Surgical Procedures Notes - Medical Finals & OSCEs Notes

Surgical Procedures Notes

Cystoscopy

Indications: haematuria protocol for bladder cancer; unusual cells found in urine sample look for bladder cancer; look at urinary blockage e.g. prostatic enlargement; look at urinary tract stones

Procedure: cystoscope into urethra, up into bladder, sterile liquid flows to inflate the bladder. Can take a biopsy or remove a stone.

Adverse effects: haematuria, pain. urethral damage can cause incontinence after rigid cystoscopy.

Any other info: flexible=local anaesthetic, rigid=general anaesthetic

Ureteroscopy

Indications: remove kidney stones

Procedure: thin cystoscope up through urethra, bladder, then ureters. Can have a basket to retrieve stone fragments.

Adverse effects: same as cystoscopy

Any other info: ‘pyeloscopy’ can go up into the renal pelvis

Nephrectomy (radical)

Indications: RCC, urothelial cancer of the kidney, living donor kidney transplantation. Renal masses >7cm.

Procedure: general anaesthetic open or laparoscopic. Can be taken out transvaginally.

Adverse effects: pain. Electrolyte and fluid balance disturbances due to kidney dysfunction. Infection, bleeding.

Partial nephrectomy

Indications: solitary kidney tumour or when removing the entire kidney could result in kidney failure or dialysis due to pathology in the other kidney. Standard where the renal mass is <4cm. Also most masses 4-7cm in size.

Procedure: GA open, laparoscopic or robotic

Adverse effects: bleeding, pain, infection, urinary leak

Any other info: better kidney function and quality of life than radical nephrectomy

Extracorporeal shock wave Lithotripsy (ESWL)

Indications: treatment of kidney stones or gallstones (or salivary stones!)

Procedure: non-invasive. Acoustic pulse. USS-guided. Fragments the stones into smaller pieces that pass. Ureteric stent can be used as well. takes about an hour. Works best with stones 4mm-20mm diameter in the kidney. Lower success if in the ureters.

Adverse effects: capillary damage with renal haemorrhage. Can lead to renal failure!

Any other info: alternatives are laser lithotripsy or percutaneous nephrolithotomy

Laser lithotripsy

Indications: removal of stones from anywhere in urinary tract

Procedure: via a cystoscope or utereroscope or pyeloscope, a laser fibre is used to deliver pulses to pulverise the stone into pieces so that they are washed out. LA or GA. Minimally invasive.

Adverse effects: very safe

Percutaneous nephrolithotomy

Indications: remove stones from the kidney that are larger than can be done by lithotripsy. Best: stones >2cm near the renal pelvis.

Procedure: do a retrograde pyelogram to locate the stone. Loin incisionneedle passed into kidney pelvis. Guide wire inserted, Seldinger technique, pass a nephroscope to take out small stones. May have to crush first with ultrasound probes.

Adverse effects: injury to colon or renal blood vessels, sepsis, pleural effusion if done through 11^th intercostal space

Sclerotherapy

Indications: treat blood vessel malformations, in particular varicose veins and haemorrhoids

Procedure: can be Us-guided. Can use glycerol or foam sclerosants to control reflux from sapheno-femoral or sapheno-popliteal junctions. Non-invasive and quick.

Adverse effects: rarely, DVT, thrombophlebitis, allergic reaction. If injected outside the vein, scarring and skin necrosis.

Carotid endarterectomy

Indications: prevent stroke by correcting carotid artery stenosis. Stenosis >70% on duplex scan. Does not matter whether symptomatic or asymptomatic.

Procedure: LA (rarely GA) open artery and remove atherosclerotic plaque. Assess cerebral perfusion using EEG. Alternatively, can do a carotid stent through a catheter from the femoral artery with balloon dilation and a wire-mesh stent. This is not as good.

Adverse effects: perioperative stroke risk or TIA. Haematomatracheal compression. Hypoglossal nerve damage. Horner’s syndrome is rare. Restenosis often occurs.

Contraindication: complete internal carotid artery obstruction (no point) or existing ipsilateral stroke (cannot cure, don’t want to worsen)

N.B.: If both arteries are suitable for repair, do not do both together, do them separately.

Abdominal aortic aneurysm repair

Indications: elective when aneurysm diameter >5.5cm on USS. growth per year of >0.5cm. emergency haemorrhage or other high risk of rupture. When blood flow is compromised e.g. to renal arteries.

Procedure: may be via an open incision or EVAR: endovascular aneurysm repair. In open, use a tube graft sutured the length of the aneurysm. EVAR=minimally invasive, via the groin and femoral arteries, place a stent-graft.

Adverse effects: 3.4% mortality for elective open repair. 1.7% for EVAR. Stent migration. Spinal or mesenteric ischaemia and distal embolic events. ‘endoleak’=failure of graft to stop blood flow to the aneurysm. Aortoenteric fistulamassive haemorrhage and death. EVAR is safer at the time but has a higher risk at 5 yrs so if life expectancy is long then do an open repair. It is not a risk of the operation to dislodge a thrombus.

When doing an AAA repair of a suprarenal or juxtarenal AAA there is clamping above the renal arteries leading to 10-15% risk of end-stage renal failure.

EVAR Contraindications: short neck length, tortuosity or angulation of iliac artery or aneurysm neck, iliac stenotic disease making catheter passing difficult.

Transurethral resection of prostate (TURP)

Indications: BPH ‘gold standard’ surgical treatment. If medical fails or there are complications (bladder stones, bladder infection, hydronephrosis).

Procedure: Remove part of prostate through urethra. Endoscopic. heated loop. General or spinal anaesthesia.

Adverse effects: retrograde ejaculation – reduced fertility – 90%. Bladder incontinence, usually for a few weeks – 10%. Urethral strictures. Haematuria for 2 weeks. Clot retention, haematospermia. UTI. Urinary retention. Erectile dysfunction 10%, usually temporary. 8% failure rate. 6% lasting stress incontinence. 10% will need a repeat TURP within 8rs. Need to avoid sex and driving for 2 weeks afterwards. Infection: UTI and prostatitis. Hypothermia.

TUR syndrome: the isotonic fluid containing glycine pumped through the urethra is absorbed into the prostatic venous sinuses and then bloodstream if the procedure is over about one hour. Leads to a decrease in temperature, fluid overload and hyponatraemia. Glycineammonia overproduction.

Alternatives: transurethral ultrasound-guided laser-induced prostatectomy (TULIP). Holmium laser ablation of the prostate (HoLAP). Open prostatectomy. TUIP.

Transurethral incision of the prostate (TUIP)

Indications: BPH

Procedure: resectoscope through urethra. Fairly similar.

Adverse effects: same as TURP but lower risk of retrograde ejaculation

Radical retropubic prostatectomy (RRP)

Indications: prostate cancer confined to the prostate, either first line or if the cancer has not responded to radiotherapy

Procedure: removed through incision in abdominal under general or spinal anaesthetic. Can be nerve-sparing if the cancer is small

Adverse effects: 40% urinary incontinence, impotence. Sildenafil may help. No semen is produced.

Other info: can be combined with lymphadenectomy to look for node involvement and stage.

Radical cystectomy

Indications: gold standard for stage T2-T3 bladder cancer. (transitional cell carcinoma). Usually first-line but can be ‘salvage’ cystectomy when radiotherapy fails. Or squamous cell carcinoma.

Procedure: removal of entire bladder and proximal urethra and nearby lymph nodes. In men the prostate, seminal vesicles and part of the vas deferens are removed. In women, the cervix, uterus, ovaries, fallopian tubes and part of the vagina are removed. Can be done open or laparoscopic.

An ileal conduit can be created to connect ureters to the skin to a stoma bag=urostomy.

Neobladder: uses small intestine to create a new storage pouch to bridge ureters and urethra.

alum solution is irrigated into the bladder to prevent massive bladder haemorrhage

Adverse effects: sexual and urinary malfunction. Massive bladder haemorrhage. Fistula formation. Infection. acidosis. Parastomal hernia, ureteric strictures, stomal stricture, recurrent UTI.

Transurethral resection of bladder tumour (TURBT)

Indications: first-line to diagnose, stage and treat visible tumours. Not for carcinoma-in-situ.

Procedure: endoscopic. Can use cutting loop or diathermy. Continuous irrigation resectoscopes. Afterwards, a single intravesicular instillation of mitomycin (or BCG) is given to reduce tumour recurrence.

Adverse effects: TUR syndrome again. Intraperitonal bladder perforation. Bleeding.

Orchidectomy

Indications: testicular cancer suspicionsend biopsy to lab during operationperform on positive histology. Or, necrotic testicle due to torsion.

Procedure: remove testicle and the full spermatic cord through an incision in the inguinal region. can have a prosthetic testicle inserted.

Adverse effects: scrotal or retroperitoneal haematoma. Ileoinguinal nerve injury. Infection.

Testicular torsion repair (surgical detorsion) & orchidopexy

Indications: testicular torsion. Within 6 hours to save testicle.

Procedure: incision through the scrotum. untangle spermatic cord and testicle. Orchidopexy of both testicles (bell clapper deformitypredisposition) is fixing it to the scrotum wall by making a dartos pouch

Adverse effects: bleeding, pain, infection, testicular atrophy.

Other info: an orchidectomy must be performed if the testicle is not salvageable i.e. necrotic

Oesophagectomy

Indications: oesophageal cancer. Before it has spread. Occasionally for achalasia or...