2 General surgical procedures

This is an aseptic procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes. It is performed 2cm below the umbilicus or 5cm superior and medial to the anterior superior iliac spine on either side. Ideally the procedure should be performed under radiological guidance.¹ One must be aware of coagulopathies, an acutely peritonitic abdomen, distended bowel, organomegaly, an abdominal wall with scars from previous surgery, pregnancy, and abdominal wall sepsis (cellulitis, fasciitis) before performing this procedure, to reduce the risk of complications.²

A needle or cannula is inserted into the radial artery (Fig. 2.1; although any peripheral artery can be used, e.g. ulnar, brachial, femoral) in order to obtain arterial blood sampling for biochemical gas analysis or to allow continuous blood pressure monitoring. The latter is used in an intraoperative or high-dependency setting.

If the radial artery is used, Allen's test should be performed to ensure adequate collateral blood supply to the hand prior to cannulation.

Common causes of joint swelling are trauma, rheumatoid arthritis, gout and osteoarthritis. Arthrocentesis is the process by which a sterile needle and syringe is used to drain fluid from a joint to reduce the pressure of fluid in an attempt to relieve pain and swelling in an acutely or chronically inflamed joint. Occasionally, this procedure is performed to obtain a sample for microbiological and biochemical analysis to determine the cause of joint swelling or exclude septic arthritis.

Arthrocentesis can be therapeutic in certain circumstances where steroids injections are performed to reduce joint inflammation and swelling. The skin is sterilized with antiseptic fluid to reduce the risk of introducing infection into the joint. A wide-bore needle is attached to a syringe and inserted into the joint space, which is often marked clinically as the most fluctuant part or dependent part of the joint. On completion the needle is withdrawn and the puncture site is sealed with a dressing.

There has been considerable debate in UK concerning consent pertaining to the transfusion of blood products, with concerns that the practice of obtaining consent for blood transfusion is inconsistent and that the relevant benefits, risks, and alternatives may not be being disclosed to patients in many cases. The issue has been recently highlighted by the recent stakeholder consultation, initiated by the UK's Independent Advisory Committee on the Safety of Blood, Tissue and Organs.¹

As with any examination, investigation, or treatment, the relevant information should be disclosed to the patient and the patient should consent to treatment with this information in hand, before commencing the intervention. Indeed, the Royal College of Surgeons of England issued a position statement in October 2010 stating that patients should be fully aware of the likelihood of blood/blood product transfusion, along with the indications, benefits, risks and alternatives before their operation.² This discussion should begin in the outpatient department and continue as part of the immediate preoperative discussion, especially if a patient is to undergo a procedure where there is a high likelihood for the need for blood transfusion.

It is the responsibility of the operating surgeon, as with consent for the operative procedure itself, to ensure that consent for perioperative blood transfusion is discussed and the outcome documented. Regarding the issue over whether consent for blood/blood product transfusion should be documented separately, the Royal College of Surgeons of England believes that best practice should be applied by using the existing national consent form and that a separate consent form is unnecessary. However, it is the clinician's responsibility to ensure that the national consent form is used properly, including disclosure of the likelihood of the need for a blood transfusion for a given procedure, and the relative benefits and risks of this.

Blood transfusions are administered more often than is necessary, as highlighted by the Chief Medical Officer, which exposes patients to needless risk and wastes valuable blood products. Therefore, it is good practice to ensure that blood products are administered only when appropriate (see the British Committee for Standards in Haematology (BCSH) guidelines³ on transfusion of red cells and separate guidance on fresh frozen plasma (FFP), cryoprecipitate, and platelets).

Blood products include:

In the case of patients who do not agree to allogeneic blood transfusion, such as Jehovah's Witnesses, it is imperative to discuss the alternatives to and consequences of refusing a blood transfusion. In some cases, patients may agree to specific blood products and it is important that this is carefully documented, with the exact products they are willing to receive.

Both the Royal College of Surgeons of England and the Association of Anaesthetists of Great Britain and Ireland have produced guidelines on the management of patients who are Jehovah's Witnesses.^2,4 For major operations where there is a likelihood of significant blood loss, planning needs to commence at an early stage.

A number of techniques can be employed to replace allogeneic blood transfusion. However, some patients may not find these techniques acceptable either, so it is important to discuss and document what is acceptable to them as an individual. Patients may already be in possession of an AD that may specify the blood products that they do not wish to receive. There are a number of other products that Jehovah's Witnesses may also find unacceptable, e.g. human albumin solution, immunoglobulins.

As with all treatments, the rationale behind the need for a blood product transfusion should be discussed with the patient, e.g. acute blood loss, symptomatic anaemia.

This is an invasive procedure where a central vein is cannulated. Its role extends beyond central vascular access and measurement of central venous pressure to guide fluid management.

Current guidelines stipulate that central venous cannulation should be performed under sonographic guidance. This is usually carried out in the operating theatre, intensive care unit or the radiology department under sterile conditions with adequate monitoring.

Commonly the internal jugular vein in the neck is used, but occasionally the subclavian vein is used (Figs. 2.2, 2.3). Rarely, in an emergency or when access to the neck is poor, the femoral vein is used for vascular access. The patient needs to be supine with head turned to the opposite side and with a 15° head down tilt. Following ultrasound identification of the vein, a needle is inserted to enable passage of a guide-wire and then cannula (Seldinger technique). The central venous line is then fixed in place with sutures and dressing.

The risk of complications increases, depending upon:

A surgical procedure used to remove skin lesions where the entire area of concern is removed for histological review. Often if the lesion is large or anatomically difficult to access, a part of the lesion can be removed and the procedure is referred to as an incisional biopsy.

This procedure is often carried out as a day procedure and is usually limited to small-sized lesions such as warts, keratoacanthomas, basal cell carcinomas and skin naevi.

Histology is reviewed and for most benign lesions no follow-up is required, with copy of the biopsy result sent to the patient's general practitioner and a letter to the patient. However, in cases of malignant lesions, clinic follow-up should be arranged to discuss results and any additional treatment if required. Rarely if the lesion is malignant and there is involvement of the excised margin, further excision or regional lymph node sampling/clearance may be required. Advice is given regarding the removal of skin sutures if non-dissolvable material is used.

This is a surgical procedure to remove fatty lumps or cysts from skin or adipose tissue deep to it. Excision is commonly performed for alleviating symptoms, which include pain, cosmesis, recurrent cyst infection, impaired limb function, and patient anxiety. In certain circumstances, lipomas may be intramuscular in nature and, therefore, more extensive excision may be necessary.

A hernia is caused by the abnormal protrusion of a viscus (in the case of groin hernias, an intra-abdominal organ) through a weakness in the containing wall. This weakness may be inherent, as in the case of inguinal, femoral, and umbilical hernias. Femoral hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring defect known as the femoral canal (Fig. 2.4). Femoral hernias are relatively uncommon, accounting for only 3% of all hernias and occur more commonly in women and in adults more than children.

Surgery is performed to relieve discomfort and to prevent complications including incarceration and strangulation. Surgery involves exploration of the groin, reduction of the hernia contents, and repair the defect with sutures or mesh.

A hernia is caused by the abnormal protrusion of a viscus (in the case of groin hernias, an intra-abdominal organ) through a weakness in the containing wall. This weakness may be inherent, as in the case of inguinal, femoral, and umbilical hernias. An inguinal hernia is a protrusion of the contents of the abdominal cavity through the inguinal canal. They are very common (lifetime risk 27% for men, 3% for women¹), and their repair is one of the most frequently performed surgical operations.

The treatment in a fit patient is usually surgical, where the contents of the hernia are reduced and the defect is closed and strengthened using a mesh (Fig. 2.5). Surgery may involve conventional open exploration of hernia through a groin incision, or by laparoscopic surgery. Laparoscopic repair offers a quicker return to work and normal activities with a decreased pain.

Several prospective randomized trials comparing open versus laparoscopic repair have reported reduced postoperative pain, earlier return to work, and fewer complications and decreased recurrence rate via a laparoscopic approach.

The discomfort from direct and indirect inguinal hernias may be reduced by a truss hernia support. This can be useful while the patient is waiting for an operation of if the patient is unfit for surgery.

The complication of laparoscopic hernia repair can be summarized as follows:²

This is a weakness or defect in the anterior abdominal wall, which may be congenital or acquired. It results in the protrusion of intra-abdominal contents, which are at risk of strangulation or obstructing, or is simply painful. The hernia is usually repaired via a transverse incision over the hernial protrusion, and may require a mesh cover if the defect is larger than 3cm or is recurrent in nature.

This hernia develops due to a weakness in the midline linea alba where the fibres of the rectus sheath decussate. It is usually repaired by primary closure of the defect, and does not routinely require a mesh unless the neck of the hernia is large.

This is an iatrogenic hernia resulting from previous incisions over the anterior abdominal wall. Incisional hernia formation is due to poor abdominal wall structure, infection, or failure in surgical technique. The rate of incisional hernia occurrence has been reported as high as 13%.¹

Both laparoscopic and open surgical repair have been used for incisional hernias. The use of mesh is dependent on the surgeon, however, it is now commonly used.

The discomfort from direct and indirect inguinal hernia may be improved by a truss hernia support. This can be useful while the patient is waiting for an operation or if the patient is unfit for surgery.

Postoperative complications include:

An abscess is a collection of pus that has accumulated in a cavity as a result of an infective process. It is a part of the host defence response to prevent the spread of sepsis systemically. Abscesses tend to present with local symptoms of pain, swelling, redness, and limitation of movement. Systemic symptoms, which include pyrexia, are not uncommon. The most common organisms involved are Staphylococcus aureus and Streptococcus. Surgical treatment is with incision and drainage of the sepsis, and those with weakened immune systems, e.g. patients on steroids or chemotherapy and patients with diabetes, renal failure on dialysis, or HIV develop abscesses frequently and need to have treatment instituted urgently.

A drain is inserted percutaneously into the pleural cavity through an intercostal space for the purpose of drainage (Fig. 2.6). This could be therapeutic in nature or diagnostic to obtain pleural fluid for biochemical, cytological, or microbiological analysis. Intercostal drain insertion can be performed by blunt dissection (surgical drain, Fig. 2.7) or via Seldinger's technique for smaller drains. Ultrasound guidance may be used to guide placement, especially for basal drains.