– Treatment
- Local aluminium chloride application
- Tympanic neurectomy (surgical division of the cross connected fibers) - Botulinium toxin injection.
MISCELLANEOUS GENERAL SURGERY
Audit topic can be
y A physical sign or symptom y A screening procedure y A diagnostic test y A diagnoses
y A treatment procedure y A follow-up procedure
Criteria that are defined should be (Mnemonic: CARES UFO) y Comprehensive
y Acceptable y Relevant y Explicit y Specific y Uniform y Feasible
y Objective and verifiable.
Ratification of criteria comes next which means passing the criteria to all the participating members of audit and seeing that the criteria are approved by all those involved.
Evaluation of records y OT registers
y Health workers diary y Follow-up register
y Medical records department
Once all this is done, evaluation and identification of remedial measures is done and remedial measures are implemented.
After implementation of remedial measures, check for compliance to new measures and if there is non compliance, do re-audit of noncompliant measures within 3 months of the implementation.
The same cycle continues as audit is a continuous process.
Q66. Discuss ethics and its impact on patient management.
Ans.
Definition
Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine.
Four pillars of medical ethics
y Autonomy: This is the right of the patient to make informed decisions on his own will y Beneficience: The doctor should always act for the betterment or welfare of the patient y Nonmaleficience: The doctor should not indulge in any action that can intentionally
harm the patient
y Justice: Justice is a complex ethical principle with meanings that range from the fair treatment of individuals to the equitable allocation of healthcare finance and resources.
Justice is concerned with the equitable distribution of benefits and burdens to individuals in hospitals or social institutions and how the rights of various individuals are realized.
It is important to remember that CONFIDENTIALITY is NOT a pillar of medical ethics.
This is an important issue because confidentiality is confirming to all the four pillars of medical ethics and is therefore considered important ethical principle to follow.
However, it is not an ethical pillar because in some situations, confidentiality may need to be broken as in following:
y To protect harm to third party y To prevent crime
y In court of law for justice y Fitness to drive
y Fitness to work where others might be affected
Tools of practice for medical ethics include 4 important components and 4 levels of each component with are mentioned below:
y Competence
– Expert competence – Shared competence – Team competence – Not competent y Resources
– Equal distribution of adequate resources – Adequate distribution possible with rationing – Scarce resources
– Inadequate resources y Abiding by law
– Action is completely protected by law – Reasonably predictable law
– Civil law not protecting the action – Illegal act
y Morality
– Uncontrovertially moral – Acceptable moral – Morally doubtful – Immoral
This means that an act by a fully competent person with adequate utilization of resources which is legally and morally appropriate for a given patient is an ethical act.
The consequence evaluation of such acts is done using the individual, family and society tool to look at the consequences of an ethical or unethical act on both the patient and the doctor side.
Implementation
y Only ethical acts are the acts of duty for a doctor y It is a doctor’s duty to:
– Follow confidentiality issues
– Provide morally and legally correct and competent healthcare to patient – Protect the rights of the third party
This emphasis on duty is part of an area of ethics called Deontology.
Q67. Write a note on universal precautions.
Enumerate the standard precautions used in surgeries to prevent against HIV.
Ans.
y Center for disease control in Atlanta gave the universal precautions in 1987 to minimize the risk of transmission of blood-borne infections
y In 1996, CDC renamed it as standard precautions to include universal precautions and body substances isolation to prevent risk of infection transmission from almost all body fluids and tissues
y These apply to all body fluids such as blood, body secretions, all body fluids such as semen, vaginal secretions, CSF, urine, etc. organs or tissues, cell cultures or tissue cultures, organ cultures, animal parts or fluids, non-intact skin and mucous membranes.
These precautions include:
y Proper handwashing
– Before and after coming in contact with any patient
– Before and after coming in contact with body fluids or specimens – Before and after glove wearing anytime
– Steps are given to standardize the technique and prevent infection transmission y Wearing double pair of gloves: Single pair does not limit risk as much as double pair
while three pairs give no added benefit y Caps and masks
y Apron
y Protective equipment for eyes and feet: Eye protection equipment include plastic glasses with side shields, goggles, chin length masks and masks with visors. The gum boots or canvas shoes are for feet protection especially while doing TURP like procedures y Prevention of needle stick injury should be done by following measures:
– No more than single pair of hands should work in an operation field.
– Use instruments to handle needles.
– Always put sharps in a tray rather than then directly.
– Direct sharp instruments should be kept away from the assisstant’s hands.
– Never directly recap a needle with two hands.
– Discard sharps with caution. Never bend the needle with hands.
– Always use puncture proof containers.
This is important because the risk of transmission due to needle sticks is 30% for HBV, 3%
for HCV and 0.3% for HIV.
Q68. What is a biopsy? What are its types?
Discuss the role of biopsy in surgery.
Ans. Biopsy is a procedure to obtain tissue for microscopical examination, usually to perform a
Indications for biopsy
y Any lesion or swelling in skin, subcutaneous tissue, muscle or organs such as liver, lung, tongue, rectum, bone marrow, prostate, brain, kidney and almost all organs in the body before excision are meant for definitive diagnoses.
y Any lesion suspicious of malignancy (Persistence of lesion or ulcer, sudden increase in size, change in character, color or consistency, bleeding to touch, becomes fixed to surrounding structures)
y Precancerous lesions (Leukoplakia, etc.)
y Inflammatory lesions: Ulcerative colitis, Crohn’s disease, amyloidoses, vasculitis, etc.
y Bone lesions not identified by clinical and radiographic findings y Nonhealing ulcers.
Types of biopsy
y Aspiration biopsy cytology or fine needle aspiration cytology (Discussed in previous question).
y Trucut biopsy
y Incisional biopsy—wedge biopsy or punch biopsy y Excisional biopsy.
Trucut (core needle) biopsy
y It is the aspiration biopsy using trucut needle with 20 mm specimen notch and centimeter depth markings that assist in depth perception and sharp cutting edge which help in cutting, high quality specimen cleanlly.
y It can be done directly by palpation or under ultrasound, MRI or stereotactic guidance or vaccum assisted core biopsy.
y Indications
– Breast lesions, liver lesions, bone lesions are common indications
y The histological architecture of the tissue is retained here as it is not aspiration but rather a type of core needle incision biopsy wherein cylinders or cores of tissues are removed and not cells alone.
Incisional biopsy
y The intent of an incisional biopsy is to sample a portion of the lesion y If the lesion is large, more than one area may require sampling y Indications
– In all the lesions which are very large to directly undergo excisional biopsy or where excision biopsy can produce functional limitations not justified for all diagnoses of the lesion, incisional biopsy is to be done first to confirm the diagnoses.
– For example, extremity soft tissue sarcomas.
y Technique
– A wedge resection of the lesion is done such that margin extend into the normal tissue on deep surface and sometimes also on the lateral surface
– Necrotic tissue should be avoided.
Punch biopsy
y Can be used for incisional or excisional biopsy .
y Technique
– Biopsy punches should range in size from 2 to 10 mm in diameter and the residual wound should be allowed to heal by secondary intention.
y Disadvantages
– It is difficult to obtain adequate, representative tissue deeper than the superficial lamina propria.
Brush biopsy
y Firm pressure with a circular brush is applied, rotated for about ten times to cause an abrasion
y The cellular material picked up by the brush is transferred to a glass slide, preserved and dried.
Excisional biopsy y Indications:
– Used for small lesions
– When complete excision with a margin of normal tissue is possible without functional debility or amputation.
y Technique
– Complete removal of the lesion with 2–3 mm normal tissue surrounding the lesion is performed
– Direct infiltration of anesthesia into the lesion and use of electrocautery near the lesion should be avoided
– The specimen should be immediately placed and completely immersed in 10%
formalin solution after orientation to allow determination of the right, left, superior, deep and inferior surfaces of the specimen
– Primary closure of the wound is usually done.
Q69. Write a note on fine needle aspiration cytology and its role in surgery.
What is aspiration biopsy cytology? Discuss its uses.
Ans. FNAC is an interventional cytology technique.
Indications
y Diagnoses of palpable mass lesions such as in breast, lymph nodes, thyroid, soft tissue lesions etc.
y Diagnoses of nonpalpable mass lesions is also done using FNAC under assistance of radiological techniques such as ultrasound, CT scan, MRI, stereotactic localization and FNAC or endoscopy guided FNAC
y Salivary gland FNAC, diagnoses of abdominal lesions, liver or lung lesions, prostate, retroperitoneal lumps, etc. are also diagnosed using FNAC.
Technique
y A syringe with 22 gauge needle is used for performing FNAC. Glass slides and suitable fixative are also required for FNAC
y The procedure is usually done with or without local anesthesia y 6–10 needle passes are made to collect adequate sample
y The cells collected are smeared on glass slides and prepared smears are wet fixed or air dried or both
y Wet fixation using Hematoxylin and Eosin stain is mainly used to study nuclei and nuclear features whereas air dried smears stained with Giemsa or Leishman stain are used to study cytoplasmic components and background stromal details.
Advantages
y It is an outpatient procedure and no hospitalization is required y It is painless and rapidly carried out
y It can be done without anesthesia y It is less traumatic than biopsy y It is cheap and safe
y Result is obtained rapidly.
Complications y Infection y Bleeding
y Pneumothorax for lung or pleural FNAC y Bile leakage or bleeding in liver FNAC y Pancreatitis after pancreas FNAC.
Disadvantages
y It is cytology, therefore, cannot differentiate with certainty between in situ and malignant lesions
y Requires experienced cytopathologists to make the reports
y In thyroid, cannot differentiate between follicular adenoma and carcinoma
y Immunohistochemical markers are not routinely available to be carried out on FNAC specimens
y Inadequate sample can result in false negative diagnoses. Therefore, a negative FNAC alone is not enough to rest assured if malignancy was suspected before the procedure and it needs to be repeated or biopsy done to establish the diagnoses with certainty.
Q70. Write a note on sterilization techniques.
What is sterilization? What is disinfection? Enumerate the techniques of sterilization.
Ans. Sterilization: Killing of all the microorganisms, either in the vegetative or spore state Disinfection: Killing of all the pathogenic organisms but not the spores
Antisepsis: Prevention of infection on skin and mucous membrane.
Techniques of sterilization and disinfection
Sunlight UV rays It is natural sterilization method Dry heat—act by
free radical mediated damage and protein denaturation
Red heat
Flaming Tip of forceps
Incineration All pathological wastes Dirty dressings
Hot air oven 160°C at 15 lb pressure for 1 hr
Used for syringes, oils and paraffin, glassware and powders
Contd...
Sunlight UV rays It is natural sterilization method Moist heat Pasteurization Milk
Inspissation 80–85°C for 1 hr on 3 consecutive days Used for Lowenstein-Jensen medium and Loeffler’s media.
Steam at 100°C
(Tyndallization) 100°C for 20 minutes on 3 consecutive days For media containing serum, egg or gelatine.
Autoclave Steam at 121°C for 15–20 minutes
Used for surgical equipment, pharmaceuticals, dressings.
Bacillus stearothermophilus or bacillus subtilis is used as control
Radiation Ionising (X-rays,
Gamma rays) Plastic material (disposable syringes, swabs, catheters, chest tubes, culture plates, ryles tube)
Non ionising (Infrared
and UV rays) Used for operation theatre sterilization Filtration Kieselghur type or
Kaolin and sand type/
sintered glass filter/
membrane filter
Used for antibiotic solution, serum or solutions containing sugar and gelatin
Chemical Alcohol Ethyl alcohol is used as skin antiseptic
Aldehyde Fumigation
2% glutaraldehyde (Cidex) for 20 minutes for disinfection
Rubber equipment, laparoscopy instruments, cystoscopy instruments, all endoscopes, endotracheal tube and oxygen mask Chlorhexidine (Phenol
group) Skin antiseptic
Ethylene oxide All tubings and presterilized catheters are sterilized by ethylene oxide or gamma rays All heart lung machines, respirators, suture materials, disposable syringes are presterilized by ethylene oxide
Formaldehyde gas Fumigation of operation theatre Betapropiolactone Better agent than formaldehyde Cationic or anionic
surface active agents (Cetavlon)
Used in antiseptic soaps
Q71. Write a note on hospital waste management.
Ans.
y Biomedical waste is defined as any waste which is generated during diagnoses, treatment or immunization of human beings or animals or in research or production or testing of biologicals
Contd...
y Of the biomedical waste generated nearly 70–80% is nonhazardous but the remaining 10–15% is hazardous and can cause health issues if it is not properly disposed off y The hazards are both to generators and to the patients and can cause infections, injury
from sharps, radiation hazards, burns, fires and many more
y Options for destruction of the waste is through one of the following techniques:
– Incineration mainly for solid wastes and soiled wastes – Wet and dry thermal treatment
– Microwave irradiation – Landfill
– Chemical disinfection using 1% hypochlorite solution mainly for liquid wastes such as blood, urine, stools or hospital sewage
y Different containers are provided for the waste segregation according to its disposal.
These containers and their colour coding are government mandated and routine checks are done to ensure the enforcement of the rules of waste disposal at hospital level y It is said that the waste segregation should begin at the site of generation and thus this
colour coding is very essential to remember. These bags are then collected by the waste disposal teams and disposed appropriately.
The color coding is as follows:
Red bag or disinfected container:
Autoclaving or chemical disinfection y Contaminated items with blood and/or body fluids.
y Waste from laboratories, microorganisms
specimens, research wastes such as cell cultures, wastes produced during pharmaceutical production of drugs, toxins, biological or cultures
y Tubings, catheters, IV sets, blood transfusion bag and sets, Urobag
Blue puncture proof container or Blue plastic bag: Chemical treatment and destruction or autoclaving and destruction or shredding
y Needles, syringes, scalpel blades, glass bottles, broken ampoules that can cause injury
Yellow plastic bag: Incineration or
landfill burial y Human tissues, organs, animal tissues and organs, body parts, human or animal waste from hospitals, colleges or animal houses
y Waste food stuff from hospital, fecal, urine soiled stuff
Black plastic bag: Landfill Burial y Empty plastic bottles, coverings of disposable tubings, noncontaminated plastic waste y Outdated, discarded medicines
y Chemicals used in production of biological, disinfectants or insecticides
Q72. Enumerate the complications of tracheostomy.
Ans. The complications of tracheostomy are as follows:
y Bleeding at tracheostomy site
– Immediate bleeding is due to poor hemostasis.
– Late bleeding is an ominous sign and suggests trachea-innominate fistula. The patient should be taken to operation theatre and immediate fiberoptic bronchoscopy and control of bleeding is to be done to save patient’s life. Temporary bleeding control can be attained by finger compression of the site
y Blockage of tube can occur with blood clots and mucus y Subcutaneous emphysema in neck
y Esophageal injury
y Injury to recurrent laryngeal nerve
y Air trapping in lungs can lead to pneumothorax and/or pneumomediastinum y Infection at tracheostomy site or airway infection
y Tracheomalacia y Tracheal stenosis
y Tracheoesophageal fistula y Accidental tube removal.
Prevention
y Appropriate size tube should be used for the procedure y Good tracheostomy care
y Suctioning to remove clots and mucus plugs y Regular checkup by ENT specialists
y Humidifying the air that passes through the tracheostomy tube
y The tracheostomy site should be routinely cleaned to prevent infection.
Q73. Classify suture materials.
Ans.
The classification of suture materials is as follows:
Absorbable natural y Plain catgut y Chromic catgut
Absorbable synthetic y Monocryl (polygliceproner) y Vicryl (polyglactin 910) y Vicryl rapid
y Dexon (polyglycolic acid) y PDS (polydioxanone) Non-absorbable natural y Silk
Non-absorbable synthetic y Prolene [polypropylene]
y Nylon
y Ethilon [Polyamide]
y Polyester Monofilament
Catgut, monocryl, PDS, prolene, ethilon Polyfilament
Vicryl, vicryl rapid, dexon, silk, polyester
Q74. Write a note on options of pain management in surgery.
Ans. Pain is a sensory and an emotional experience that is brought about by actual or potential tissue damage or described in terms of tissue damage.
y Acute pain: Pain duration < 1 month and pain that resolves within hours or at the most few days after the wihtdrawl of the stimulus or wound healing.
y Chronic pain: Pain that persists > 1 month beyond the expected time of healing/
recovery.
Types of pain
y Nociceptive pain (muscle or viscera or skin and subcutaneous tissue origin) y Neuropathic pain (nerve origin)
y Psychogenic pain (mental origin).
Pain control methods in chronic painful conditions are as follows:
y Local medications such as anesthetic drugs, topical analgesia, topical steroids y Nerve stimulation procedures such as acupuncture, transcutaneous electrical nerve
stimulation (TENS)
y The pain management step ladder for oral and parenteral analgesics – Simple analgesics: Aspirin and NSAIDs
– Second step analgesics: Tricyclics, Pregabalin – Third step: Mild opioids such as tramadol
– Final stand: morphine—oral, parenteral or epidural—continuous or patient controlled y Management of phantom limb as described in the question on amputation is an example
of pain management for chronic conditions and should be described here as an example.
Pain management of malignant conditions
y This also begins with the analgesic step ladder and proceeds to further neurolytic nonsurgical and surgical techniques
y These include techniques such as celiac ganglion block for pain due to pancreatic cancer, intrathecal neurolysis, anterolateral cordotomy as well as radiation therapy for pain relief (This is described in the question on functional neurosurgery in neurosurgery section) y Other methods of pain relief involve hormones such as steroids and anti-pituitary drugs,
psychotherapy, group therapy, physiotherapy and anticonvulsants can also be used for pain relief in these conditions.