Surgical Procedures Osce Notes

Surgical procedures

Rigid Sigmoidoscopy

• Identification:

• Indications: investigation of anorectal symptoms in OPD. Visualises rectum and allows biopsy. Can conservatively treat sigmoid volvulus. Can see polyps and haemorrhoids.

• Consent: Explain indication and procedure and risks.

• How to do it: Position patient in left lateral position with hips flexed but knees part extended. Do DRE first as it should not be performed if there are painful anal fissures. Lubricate the sigmoidoscope and insert with the obturator (white bit) in place for the first cm. Then remove the obturator and add a light source and insufflator and eyepiece. Insufflate the rectum, don’t advance unless you can see. Also withdraw under direct vision. Look around. Withdraw, clean patient.

• Risks/complications: Pain. Bleeding. Infection. Uncomfortable desire to defaecate. Rarely, perforation.

• Record keeping: Lesions size and position, whether a biopsy was taken, any complications.

Proctoscopy

• Identification:

• Indications: Investigation/visualisation of anorectal conditions. Similar to a rigid sigmoidoscopy. Allows treatment of haemorrhoids. Screening for cancer/cytology biopsy. Remove a foreign body from anal canal.

• Consent: Risks, procedure, indications, any questions.

• How to do it: Patient in lateral position with top leg flexed at the knee and hip. Visual inspection and DRE and lubricate. Slowly advance the proctoscope, ask patient to bear down. Remove obturator once it is fully inserted. Slowly withdraw it and examine the mucosa at the same time.

• Risks/complications: Mucosal irritation and bleeding. It may be painful if there are anal fissures.

• Record keeping: The procedure and results and any complications.

Arterial Blood gas

• Identification: Look for heparinised paper.

• Indications: Acute emergency blood sample in ITU or resus, that gives information on haemoglobin and electrolytes. Also used for assessing acidosis or alkalosis, arterial gas saturations (partial pressures), identify metabolic or respiratory or mixed acid base disorders, gives an oxyhaemoglobin and glucose and lactate. Assesses response to therapeutic interventions.

• Consent: Pain, risks, indication, questions.

• How to do it: Select site by palpating arteries. Use Allen’s test. Prepare the skin, use local anaesthetic. Advance the syringe/needle after moving syringe up slightly, use fingers to tether or to indicate where pulse is. Await arterial blood flashback. Apply pressure for 5 mins afterwards. Analyse blood gas.

• Risks/complications: Pain. Missed vessel, get a venous sample, need to do it again. Haematoma common. Infection. Rarely: compartment syndrome, artery laceration.

• Record keeping: Technique and results into notes.

IV Cannulation

• Identification: A cannula/venflon.

• Indications: IV access for giving drugs, IV fluids, blood. Can take blood at same time. IV radiological contrast. Emergency tension pneumothorax aspiration.

• Consent: Advise of reason and risks and that it will be painful. Talk about changing it and taking it out when unnecessary.

• How to do it: Use tourniquet and select area, clean, palpate vein, clean. Tether skin, insert cannula 1cm distil to point of entry. Advance until flashback. When flashback, advance cannula without advancing needle and withdraw needle slowly, taking tourniquet off just before it comes out. Fix cap on or take blood at this point. Alternatively, to prevent blood flow, remove tourniquet, compress vein proximally, withdraw needle. Secure with dressing. Flush with saline. Dress, record, etc.

• Risks/complications: Pain. Failure to access/tissuing. Arterial puncture. Thrombophlebitis. Rarely: peripheral nerve palsy, compartment syndrome, skin and soft tissue necrosis.

• Record keeping: record that a cannula has been inserted, put the date on it. Draw in drug chart.

NG tube insertion

• Identification: Some are radioopaque at the end for CXR. Some are thin, yellow, with wire=feeding. Some are large, clear=obstruction.

• Indications: Intestinal obstruction. Evaluation of UGI bleed (volume, presence of blood). Paralytic ileus. Perioperative gastric decompression. Enteral feeding. Contraindicated where possible basal skull fracture.

• Consent: Indication. Procedure & risks. Advise to swallow lots and people get used to it. Any questions?

• How to do it: Position patient sitting with head tilted forward. Ask to cover one nostril and breathe, and the other, to see which is clearest. Estimate the required tube length, from the alar (nose wing ) to stomach. Alar, loop around ear, down to 5cm below the xiphisternum, mark/note measurement. Lubricate NG tube with gel, not too much or it will obstruct holes so no flushing. Pass it horizontally towards the occiput along the floor of the nasal canal. When the tube reaches the pharynx, ask the patient to swallow from a glass of water and keep taking sips and reassure them as they will gag. Continue to where you measured. Check the position – they should not be coughing. Aspirate fluid and test with litmus paper for pH<5.5. can also blow air into the tube and auscultate with stethoscope for gurgles. A CXR is needed.

• Risks/complications: Discontent, gagging, epistaxis. Malpositionaspiration pneumonia and death. Oesophageal perforation is very rare.

• Record keeping: Reason for insertion. Type/volume of drained fluid. Type/size/length of tube. That it has been confirmed in place: Litmus result, CXR. If coughing during procedure.

Lumbar puncture

• Identification:

• Indications: Suspected meningitis or subarachnoid haemorrhage. Guillain-Barre or carcinamatous meningitis. Anaesthetics if an epidural. Relieved increased intracranial pressure.

• Consent: Reason, anaesthetic, answer questions, explain risks fully.

• How to do it: Position the patient in the lateral recumbent...

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