GENERAL SURGERY For Dental Student

GENERAL SURGERY
For Dental Student
By
Dr. GhassanN. Taleb
(Maxillofacial Surgeon)
Prepared & Designed by:
Mohammed M. Nasser
(Student at College of Dentistry)

1 Introduction
2 Case History & General Examination
3 ATLS (Advance Trauma Life Support)
4 Fracture & Dislocation
5 Neck Lump
6 Ulcers
7 Tumor
8 Surgical Wound & Infection
9 Wound Healing
10 OroantralFistula
11 Hemorrhage
12 General Anaesthesia(GA)
13 Fluid and Electrolyte Management
of the Surgical Patient
Contents

General surgery means a surgical specialty that
associated with wide range of surgical procedures that
performed on soft tissues.
Anything from small lesion in the skin to the large cyst
and colectomy, also it is associated with all content of
the abdomen starting from the esophagus, stomach,
small & large intestine, liver, spleen, bile duct and thyroid
gland.
1Introduction
Classification of Surgical Diseases
it can be mechanical such as any machinery or
instrument trauma, thermal due to the over heat,
chemicals,some chemicals and chemical
products, electrical and war.
1-Trauma
abscess, sinus…2-Infection
benign or malignant3-Neoplasia
congenital or acquired, likeacromegaly.4-Anatomical
abnormalities
like diabetes mellitus, goiter, hyper or hypo
thyroidism, hyper or hypo parathyroidism.
5-Metabolic
and
hormonal
disorder
This is usually effectively on heart like coronary
artery disease.
6-Infarction
& ischemia
obstruction, parasite diseases, vein varicose7-Others

According to: Characteristics, Operation methods, Age
and Specialty.
1) According to characteristics:
a) Neoplastic surgery: surgery associated with any
neoplasia like tumors either malignant or benign.
b) Emergency surgery: surgery associated with the
urgent cases.
c) Trauma surgery: it’s any surgery associated with the
traumatic injury like chemical, mechanical or electrical
trauma.
d) Burn surgery: this surgery associated with burn
injury.
2) According to Operation methods:
a) Plastic surgery: the surgery that treats any
deformity associated with the body.
b) Microsurgery: the surgery that uses microscope like
repair of the fine blood vessels.
c) Transplantation: it is the surgery that associated
with transplants of any tissue or organ of the body
from donor to recipient.
d) Minimally invasive surgery: any surgical procedure
that uses a minimal or least aggressive way to treat
any lesion.
Classification of surgical specialties

3) According to Age:
a) Pediatric surgery: surgery treats the patient less
than 12 years old.
b) Adult surgery: the surgery that associated with
treatment of any patient aged more than 12 years old.
4) According to Specialty:
a) General surgery: as we previously mentioned the
surgery that associated with any tissue or organ
present in the abdomen like esophagus, spleen, liver,
intestine and others.
b) Orthopedic: surgery that associated with bones
and their lesions.
c) Neurosurgery: surgery treats any neurological
deformities or deficient.
d) Gynecological: surgery that associated with any
gynecological disease in the women.
e) Otolaryngology (ENT): surgery that associated with
any lesion present in ear, nose or throat.
f) Ophthalmology: surgery treats any lesion in the eye
or ophthalmic.
g) Maxillofacial: surgery or specialty that associated
with any lesion in the head and neck, especially the
face and two jaws (upper and lower).
h) Plastic: treats any deformities in the body.
i) Cardiovascular: surgery associated with heart and
the vascular lesions.

Classification of surgical specialties
a) Pediatric surgery:
pt. less than 12
years old.
b) Adult surgery: pt.
more than 12 years
old.
a) General surgery.
b) Orthopedic.
c) Neurosurgery.
d) Gynecological.
e) Otolaryngology
(ENT).
f) Ophthalmology.
g) Maxillofacial.
h) Plastic.
i) Cardiovascular.
a) Plastic surgery.
b) Microsurgery.
c) Transplantation.
d) Minimally
invasive surgery.
a) Neoplastic
surgery.
b) Emergency
surgery.
c) Trauma surgery.
d) Burn surgery.
3) Age 4) Specialty
2) Operation
methods
1) Characteristics

Name
Age
Gender
Address
Date of admission
Occupation
2Case History & General Examination
Body location or site
Quality and severity
Duration, onset, frequency and periodicity
Aggravating and alleviating factors
Associates manifestations
Review of any other symptoms
Previous history of similar symptoms
Personal information
Presenting problem / Chief Complaint
& History of Present Illness
Case History
Previous hospital admissions
Past operations or investigations
Major illnesses; rheumatic fever, diabetes, heart
disease, jaundice
Accidents and injuries
Past medical & surgical history
Drug history {Medication & Drug allergy}.

Causes and age of death of parents
Health of children
Information about heart disease, hypertension,
diabetes, asthma, allergies and ethnic origin.
Family history
Social history: General well being, alcohol, smoking,
housing, occupation and financial state
GENERAL
Fatigue, malaise, Fever, rigors, night sweats
Weight, appetite
Skin: rashes, bruising
Sleep disturbance
CARDIOVASCULAR
Chest pain, angina
Shortness of breath (including on exercise)
Orthopnoea, Paroxysmal nocturnal dyspnoea
Palpitations
Ankle swelling
RESPIRATORY
Systemic Review
Chest pain
Shortness of breath
wheeze
Cough
Sputum
Haemoptysis
Exercise tolerance

GASTROINTESTINAL
Appetite,weightloss
Dysphagia
Nausea,vomiting,haematemesis
Indigestion,heartburn
Jaundice
Abdominal pain
Bowels: change,constipation,diarrhoea, description of
stool,blood,mucus,flatus
MUSCULOSKELETAL
Pain,swelling, stiffness–muscles,joints, back
Restriction of movement or function
Power
Able to wash and dress without difficulty
Able to climb up and down stairs
CENTRAL NERVOUS SYSTEM
Headaches
Fits, faints, loss of consciousness
Dizziness
Vision –acuity, diplopia
Hearing
Weakness
Numbness/tingling
Loss of memory, personality change
Anxiety, depression

If the presenting complaint is pain using the mnemonic
‘SOCRATES’
S-site
O-onset
C-character
R-radiation
A-associations
T-timing
E-exacerbating & relieving factors
S-severity
* Remember to ask about use of medication for pain
relief.
Pain History

General Examination
Inspect(look at).
Palpate(touch, put pressure on).
Percuss(Tap).
Auscultate(listen to).
Approach to examination
Site
Size
Shape
Consistency
Temperature
Mobility
Tethering
Duration
Examining a Lump
Abdominal PalpationPercussion Technique

Inspection (Look)
Location/ position.
Contour (regular or irregular).
Pulsation (aneurysm or high blood flow).
Colourof skin (red, pigmented, etc).
Abnormalities in skin (peaud’orange).
Abnormal vessels.
palpation
Consistency (Soft, firm, hard, rubbery; uniform,
lobulated)
Emptying
Fluctuation
Position (measured from a landmark)
Surface (smooth, rough, irregular)
Shape
Size (tape measure)
Tenderness
Temperature
Thrill or pulsation
Movememt(plane of attachment)
Skin Tethering (attempt to pick up a fold of skin over
the swelling and compare with other side)
Deeper structures (attempt to move the swelling in
different planes relative to surrounding tissues)
Muscles and tendons (palpate the swelling whilst
asking the patient to use the relevant muscle)
Procedure

Transillumination(if
you suspect the mass
is filled with clear
fluid, ega hydrocoele)
Auscultation(for bruits
or bowel sounds)
Specific Tests
Examine for any evidence of lymphadenopathyin the
head or neck.
Be sure to examine the back of the head in the area of
the occipital nodes.
Observe for symmetry between both sides
Lymph Node Palpation
Palpate the head and neck lymph nodes in a systematic
way:
1. Occiptalnodes: Locate the occiptalnodes at the base
of the skull
Head and Neck Lymph Node Examination
TransilluminationTest
Examination of relevant regional lymph nodes
Regional Lymph Nodes

2. Posterior auricular nodes: Palpate just posterior to the
ear, above the mastoid process
3. Preauricularnodes: Palpate just anterior to the ear
4. Submental nodes: Palpate just posterior to the tip of
the mandible.
5. Submandibular nodes: Palpate along the body of the
mandible
6. Superficial cervical nodes: Palpate along the sternal
head of the sternocleidomastoid muscle
7. Posterior cervical nodes: Palpate along the clavicular
head of the sternorcleidomastoidmuscle
8. Deep cervical nodes: Palpate deeply along the sternal
head of the sternocleidomastoid muscle
9. Supraclavicular nodes: Palpate above the clavicles
10. Infraclavicularnodes: Palpate below the clavicles
When a lymph
node is found, it is
important to
comment on the
following
characteristics:
-Location
-Size
-Shape (regular vs
irregular border)
-Mobility (mobile
vs fixed)
-Tenderness
(tender vs non-
tender)
-Texture (soft vs
firm)

Radiographic examination, Biopsy, and Laboratory
test:
1-Complete blood count (CBC)
2-Erythrocyte sedimentation rate (ESR)
3-Fast blood sugar (FBS)
4-Renal function test (RFT)
5-Liver function test (LFT)
6-General urine examination (GUE)
7-Serum electrolytes (Na+, K+, Ca+, Mg+, Cl-, ……)
8-Chest x-ray (CXR)
9-Blood group (BG)
10-Electrocardiogram (ECG)
11-Radiologicevaluation (conventional, C.T., MRI...)
12-Biopsy(incisional, excisional, punch, ...)
13-Fine needle aspiration cytology (FNAC).
Investigations

Prehospital phase:-
Airway maintenance.
Control of external bleeding & shock.
Immobilization of the patient.
Communication with receiving hospital & immediate
transport to the closest, appropriate facility.
History taking (include events)
3ATLS (Advance Trauma Life Support)
Primary survey
A-Airway with Cervical Spine Control.
B-Breathing and Ventilation.
C-Circulation and Hemorrhage Control.
D-Disability (Neurological Status).
E-Exposure + environmental control.
Prehospital phase
Primary survey
PREPARATION AND TRANSPORT

The causes of upper airway obstruction may be:-
•Bleeding from oral or facial structures.
•Aspiration of foreign materials, teeth, denture
•Facial fractures.
•Airway structure trauma.
•Regurgitation of stomach contents.
•Commonly, the upper airway is obstructed by the
position of the tongue, especially in the unconscious
patient.
•Hematoma.
A-Airway Maintenance with Cervical Spine Control
Chin lift + suctionJaw thrust + suction
Control airway:
•Chin lift
•Jaw thrust
•Suction
•Oropharyngeal and
nasopharyngeal airway
•Laryngeal mask airway
•Laryngeal tube airway
•Definitive airway
•Surgical away.

Definitive airway:-
Definitive airway define as an inflated cuffed tube in
the trachea.
Types:-
1. Orotrachealtube.
2. Nasotrachealtube.
Indication:-
1. Unconscious (GCS <8)
2. Apnea
3. Inability to maintain patent air way by other means.
4. The need to protect the lower airway from blood and
vomit.
5. The need for mechanical ventilation
A-Airway Maintenance with Cervical Spine Control

Surgical airways:-
1.Needle cricothyroidotom:-It is immediate life saving
procedure.
2.Surgical cricothyroidotomy.
A-Airway Maintenance with Cervical Spine Control
Needle cricothyroidotom
Surgical cricothyroidotomy

Cervical spine control
* With any patient
sustaining injuries above
the clavicle or with
decreased levels of
consciousness, one
should assume there
may be a cervical spine
injury.
* Avoid hyperextension
or hyperflexionof the
patient’s neck .
* Definitive cervical
spine control requires:-
1. Immobilization of
neck in neutral
position.
2. Semirigidcervical
collar.
3. Head blocks
4. Tape over forehead
and chin.
A-Airway Maintenance with Cervical Spine Control

1. Inspection:
* Chest wall should be inspected for bruising, flail chest,
and bleeding.
* Neck should be evaluated for evidence oftracheal
deviation, subcutaneous emphysema, anddistended
jugular veins.
2. Palpation:
Chest should be palpated for the presence ofrib or
sternal fractures, subcutaneous emphysema, and
wounds.
3. Auscultation:
A lack or abnormal breathing sounds.
B-Breathing and ventilation

Assess for:
Shock
External bleeding
Occult bleeding
Estimate the blood loss on initial presentation of patient
and the signs and symptom:-
1.Level of consciousness.
2.Respiratory rate.
3.skin perfusion.
4.pulse rate.
5.Blood pressure.
6.Urinary output.
7.mental status.
Shock
* The most common cause of shock in the traumatized
patient is hypovolemiacaused by hemorrhage, either
externally or internally into body cavities.
* Inadequate tissue perfusion can cause irreversible
damage to vital organs such as the brain or kidneys in a
short time.
* Decreased intravascular volume secondary to blood
loss lead to:-
1.Decreased pulse pressure.
2.Rapid pulse
3.Diminished capillary refill, and cool, clammy skin.
4.Decreased urinary output
C-Circulation and hemorrhage control

Management of hypovolemic shock:
two large-bore intravenous lines placed (14-or 16-
gauge). The antecubital fossa are the preferred sites.
A blood specimen should be simultaneously obtained
for cross-matching, typing, hematological and
chemical study.
Resuscitation should consist of an initial bolus of 2 L
(20ML/Kg for pediatric patient) of a balanced salt
solution 0.9 % normal saline or Ringer's solution.
Protect from Hypothermia : 39
o
C warm IV fluid
Urinary/gastric catheters unless contraindication
Control of bleeding
Direct pressureto the wound.
Suturing:-Scalp or skin wounds may best be managed
with immediate closure with large monofilament
sutures.
Packing.
Ligation
Splinting, casting, or fixation of fracture
C-Circulation and hemorrhage control

Disability assessed by AVPUmethod
A. Alert obeys commands
V. respond to vocal stimuli
P. Responds to pain
U. Unresponsive
NEUROLOGIC ASSESSMENT:-
GCS SCALE .
Pupil reaction to light.
Limb movement.
Glasgow Coma Scale (GCS)
* 15 = normal.
* 13 or 14 = mild injury.
* 9–12 = moderate injury.
* 3–8 = severe injury.
D-Disability (neurological status)

The patient should be completely disrobed so that all
of the body can be visualized, palpated, and examined
for injuries or bleeding sites. The clothing must be
completely removed.
The patient must be quickly covered with warming
blankets.
Use of a patient warming system.
Use of fluid warmers.
Increase room temperature.
E-Exposure + environmental control
Secondary survey does not begin until the primary
survey is completed, resuscitative efforts are established
and patient is demonstrating normalization of vital
functions.
Includes:-
1. Subjective assessment:-AMPLE history.
2.Objective assessment :-Inspection, palpation,
percussion, and auscultation of the patient from head to
toe.
Secondary survey

AMPLE HISTORY
Allergy
Medications currently taking.
Past medical , surgical and social history.
Last meal.
Events / environment related to injury.
Skull fracture (cranial vault or base of skull)
The classic signs of a skull base fracture:-
Retroauricularecchymosis(battle’s sign).
Periorbital ecchymosis(raccoon eyes).
CSF leakage.
Cranial nerve VII or VIIImay affected
Carotid arteriesmay affected .
Secondary survey
Battle’s sign
Raccoon eyes

Pupillary light reflex
In normal activity when light is shone in one eye both
pupils constrict equally The size, shape, and reactivity of
the pupil to light provide information about second and
third nerve function and midbrain activity.
Secondary survey
Comprehensive Treatment of all Injuries.
Fracture Stabilization.
Necessary Operative Intervention.
Appropriate Intensive Care.
Rehabilitation.
Stabilization Appropriate Transfer.
Definitive care

Bone Fracture: damage in the
continuity of a bone.
4Fracture & Dislocation
Bone Fracture
Simple fracture:-one
line fracture with no
continuity to external
surface& no tissue
tearing.
Compound fracture:-
fracture with
communication with
the external surface.
Comminuted fracture:-
several pieces fracture.
Greenstick fracture:-
involve only one
cortex.
Classification
Simple fracture
Compound
fracture
Comminuted
fracture

1. History
Diagnosis of fractured jaw
Diagnosis of fractured jaw
1. History
2. Clinical
examination
3. Investigation
2. Clinical examination
Inspection
• Derangement or malocclusion of teeth.
• Bleeding in P.D.L.
• Ecchymosis.
• Limitation mouth opening (trismus).
Palpation
• Mobility of fracture line.
• Step deformity.
• Parasthesia.
• Crepitus.
• Pain.
3. Investigation (radio-graphical
examination)
To define the type of fracture & no. of
fracture lines.
Ex. X-ray, C.T.Scan.

Reduction.
Fixation.
Open:-flap & fix bone directly by plate.
Close:-intermaxillaryfixation (IMF).
Treatment
Open
Close

1. Unilateral:Deviation
to lateral side.
2. Bilateral: Anteriorly
open bite.
Another classification:
1. Acute
2. Chronic
3. Recurrence:Multiple
visit to hospital for
management.
Dislocation of condyle
Dislocation of condyle: condylar position anterior and
superior to the articular eminence that is not self-
reducing.
Classification
Unilateral
dislocationBilateral
dislocation
Anatomy of TMT

How to differentiate between fracture & Displacement:
No pain.
No swelling.
No bleeding.
If it due to trauma should have a radiograph.
Reduction is accomplished by pressing the mandible
downwardand then backwardto relocate the condyle
within the glenoid fossa.
Instructions.
Management

A neck lump is any congenital or acquired mass arising in
the anterior or posterior triangles of the neck between
the clavicles inferiorly and the mandible and base of the
skull superiorly.
5Neck lump
Definition
Anatomy

Thyroid
Goitre
cyst
Neoplasm
Neoplasm
Metastatic carcinoma
Primary lymphoma
Salivary gland tumour
Sternocleidomastoid tumour
Carotid body tumour
Inflammatory
Acute infective adenopathy
Collar stud abscess
Cystic hygroma
Branchial cyst
Parotitis
Congenital
Thyroglossalduct cyst
Dermoidcyst
Torticollis
Vascular
Subclavian aneurysm
Subclavian ectasia
Differential diagnosis

Congenital and inflammatory lesions are common.
1) Cystic hygroma
Is an often congenital multiloculatedlymphatic lesion
that can arise anywhere, but is classically found in the
left posterior triangle of the neck.
It contains large cyst-like cavities containing lymph, a
watery fluid that circulates throughout the lymphatic
system.
It can be can grow very large and may affect breathing
and swallowing.
2) Thyroglossalor dermoidcyst
Is a fibrous cystthat forms from a persistent thyroglossal
duct. defined as an irregular neck mass or a lump which
had developed from cells and tissues left over after the
formation of the thyroid gland during developmental
stages.
Thyroglossalcysts are the most common cause of
midline neck masses and are generally located
substandard to the hyoid bone, yet these neck masses
can occur anywhere along the path of the thyroid gland
from the base of the tongue to the suprasternal notch.
Important diagnostic features
Children

3) branchial cleft cyst
Is a congenital epithelial cyst, that arises on the lateral
part of the neck.
Usually due to failure of obliteration of the second
branchial cleft (or failure of fusion of the second and
third branchial arches)in embryonic development. Less
commonly, the cysts can develop from the first, third, or
fourth clefts.
4) Torticollis
Rock-hard mass, more prominent with head flexed,
associated with fixed rotation (a fibrous mass in the
sternocleidomastoid muscle).
5) Viral/bacterial adenitis:
Usually affects jugular nodes, multiple, tender masses.
6) Neoplasms
Are unusualin children (lymphomamost common).
Important diagnostic features
Children

Inflammatoryneck masses and thyroid malignancy are
common.
Viral (e.g. infectious mononucleosis) or bacterial
(tonsillitis/pharyngitis) adenitis.
Papillary thyroid cancer: isolated, non-tender, thyroid
mass, possible lymphadenopathy.
Important diagnostic features
Young adults
Neck lumps are malignant until proven otherwise.
1. Metastatic lymphadenopathy: multiple, rock-hard,
nontender, tendency to be fixed.
2. 75% in primary head and neck (thyroid, nasopharynx,
tonsils, larynx, pharynx),25% from infraclavicularprimary
(stomach, pancreas, lung).
3. Primary lymphadenopathy (thyroid, lymphoma): fleshy,
matted, rubbery, large size.
4. Primary neoplasm (thyroid, salivary tumour): firm,
nontender, fixed to tissue of origin.
Over-40s

U/S scan:Solid/cystic lump differentiation
Fine Needle Aspiration Cytology (FNAC)for
histopathological study
CXR;to check any associated lesion in the chest like
primary tumor or secondary metastasis
CT Scan of head, neck, chest and abdomento search
about sourseof malignancy.
Biobsyfor histopathological study
Auroscopy, Nasopharyngoscopy, Laryngoscopy,
Bronchoscopy, Gastroscopy.
Investigations

Ulcer: A break in the continuity of the covering
epithelium of the skin or mucous membrane, It may
either follow molecular death of the surface epithelium
or its traumatic removal.
6Ulcers
Etiology
Traumatic
cause:
Mechanical.
physical like electrical, radiation.
Chemical.
Vascular
insufficiency:
Arterial.
Venous.
Neoplastic
conditions:
SCC (Squamous cell carcinoma).
BCC (Basal cell carcinoma).
Malignant melanoma.
Metabolic
disease:
Diabetus mellitus.
Malnutrition:
Beriberi.
Tropical ulcer.
Infective
process:
TB (Tuberculous).
Syphilis.
Fungal infection.
Neurogenic:
Peripheral neuropathy.
Bed sore.

A-Non-specific ulcers:These include:
Traumatic ulcers.
Arterial ulcers due to ischemia e.g. gangrene .
Venous ulcers e.g. Varicose ulce.
Neurogenic ulcers (trophic ulcer).
Ulcers associated with malnutrition.
Ulcers associated with other diseases e.g. Anemia,
Avitaminosis, Gout, Rheumatoid arthritis .
Miscellaneous ulcer.
B-Specific ulcers:These include:
Infective ulcerse.g. syphilitic ulcers, Tuberculous
ulcer, fungal ulcers, Buruliulcer (a neglected
tropical disease caused by infection with
Mycobacterium ulcerans).
C-Malignant ulcers: These include:
Squamous cell carcinoma.
Basal cell carcinoma (rodent ulcer) .
Malignant melanoma.
Ulcerating adenocarcinoma.
Pathological classification
Pathological classification
Non-specific
ulcers.
Specific ulcers.
Malignant
ulcers.

Note the following:-
1) Duration(i.e. how long is the ulcer present?)
A-Acute: present for short time.
B-Chronic: present for long time.
2) Mode of onset(i.e. how has the ulcer developed?)
A-Following trauma.
B-Spontaneouslye.g. following-swelling e.g. ulcerating
lymph node in Tuberculosis or a scar of burn Marjolin's
ulcer .
C-Marjolin'sulcers are the malignant transformation of
chronic wounds.
3) Pain(i.e. is the ulcer painful?)
A-Painful: ulcers associated with inflammation .
B-Slight painful: tuberculous ulcer .
C-Painlesse.g. syphilitic, neurogenic, malignant ulcers.
4) Discharge(i.e. does the ulcer discharge or not?)
If YES: note the nature of discharge-pus, bloody, serous.
5) Associated diseaseswhich may lead to ulcer formation
e.g. Tuberculosis, Syphilis, Diabetes Mellitus, nervous
diseases.
I) History:
History Physical examination
Clinical presentation

Inspection
Edge: five types:-
1.Sloping edgee.g. healing ulcer .
2.Punched out edgee.g. Gummatousulcer, deep
trophic ulcer
3.Undermined edgee.g. tuberculousulcer-destroy
subcutaneous faster the skin.
4.Raised edgee.g. Rodent ulcer.
5.Rolled out(everted)-e.g. Squamous Cell Carcinoma .
II) Physical examination:
Physical
examination
A-General
examination
B-Local
examination
C-Systemic
examination
Inspection Palpation
Examination of lymph
node
Examination of vascular
insufficiency
Local examination

The Types of ulcer edge:
Sloping edge
(a healing ulcer)
Punched out edge
(Syphilis, trophic ulcer)
Undermined edge
(tuberculous ulcer)
Rolled
(Basal Cell Carcinoma)
Everted
(Squamous Cell Carcinoma)

* Depends on the cause
* Generally → treat the cause
I) Conservative treatment.
II) Surgical treatment.
I) Conservative treatment:
1.Dressing.
2.Treatinfections: Bacteria, fungal, syphilis, TB etc.
3.Steroids.
4.Trace elements.
5.Topical antimicrobialagents.
6.Nutritionalsupport.
7.Limb elevation.
8.Control blood glucose.
9.Hyperbaric oxygen therapy.
10.Compression bandage.
II) Surgical treatment:
1.Surgical debridement.
2.Sloughectomy.
3.Skin grafting.
4.Flaps.
5.Limb amputation.
Treatment

Atumor, also known as aneoplasm, is an abnormalmass
of tissuewhich may be solid or fluid-filled
Tumors can be:
1. Benign(not cancerous).
2. Pre-malignant(pre-cancerous).
3. Malignant(cancerous).
7Tumor
A benign tumor (benign neoplasm) cannot metastasize,
it cannot spread, means it is non-progressive.
Most benign tumors are not harmful to human health.
Even though they are not cancerous, some may press
against nerves or blood vessels and cause pain or other
pressure effects.
Benign tumors of endocrine tissues may result in the
excessive production of some hormones.
Examples of benign tumors include: Adenomas, Fibroids
(fibromas), Hemangiomas, Lipomas.
Introduction
Benign tumors

* Adenomas are tumors that arise from glandular
epithelial tissue; epithelial tissue is the thin membrane
that covers glands, organs and other structures in the
body.
* A polyp in the colon is a type of adenoma.
Adenomas
* Fibroids (fibromas) are benign tumors that grow on
fibrous or connective tissueof any organ in the body.
* Uterine fibroids are common; uterine fibroids can
cause vaginal bleeding, pelvic pain or discomfort.
Fibroids (fibromas)
* Hemangiomas are benign tumors
which consists of a collection of too
many blood cells. They can sometimes
be seen on the surface of the skin.
* The majority of hemangiomas appear
at birth and gradually go away after
some months or years. Hemangiomas
do not usually require any treatment.
* If they affect the patient's ability to
eat, hear or see, the doctor may
recommend treatment with
corticosteroids.
* If the patient is over 10 years of age,
they are more commonly removed
today using laser surgery.
Hemangiomas

* Lipomas are the most common form of soft-tissue
tumor. Lipomas consist of adipose tissue (fat cells).
* Most of them are very small, painless, soft to the
touch, and generally movable.
* They are more common among people aged 40+ years.
* There are many kinds of lipomas, such as
angiolipoleiomyoma, angiolipoma, chondroidlipoma,
corpus callosum lipoma.
Lipomas
* A premalignant defined as morphologically altered
tissue in which the development of malignancy is more
likely than with normal mucosa.
* Examples of benign tumors include: Leukoplakia,
Erythroplakia, and Chronic hyperplastic candidiasis.
Premalignant tumors
Leukoplakia is defined as a white patch or plaque that
cannot be characterized clinically or ascribed to any
other pathologic disease.
Leukoplakia
Proliferative verrucous
leukoplakia
Typical appearance of
erythroleukoplakia

* For diseases in which abnormal cells divide without
control and can invade nearby tissues. Cancer cells can
also spread to other parts of the body through the blood
and lymph systems.
* There are several main types of cancer:
-Carcinomais a cancer that begins in the skinor in
tissues that line or cover internal organs.
-Sarcomais a cancer that begins in bone, cartilage, fat,
muscle, blood vessels, or other connective or supportive
tissue.
-Leukemiais a cancer that starts in blood-forming tissue,
such as the bone marrow, and causes large numbers of
abnormal blood cells to be produced and enter the
blood.
-Lymphoma and multiple myelomaare cancers that
begin in the cells of the immune system.
-Central nervous system cancersare cancers that begin
in the tissues of the brain and spinal cord.
* Also called malignancy.
Malignant tumors

T = Tumor Size
T1< 2 cm
T2> 2 cm and ≤ 4 cm
T3> 4 cm
T4Tumor invades through cortical bone inferior
alveolar nerve, floor of mouth, or skin of face (e.g.,
chin or nose)
N = Nodal Metastasis (Regional)
N0: No regional nodes palpable.
N1: Single ipsilateral node < 3 cm.
N2: Metastasis in a single ipsilateral lymph node, > 3
cm but ≤6 cm; or in multiple ipsilateral lymph nodes,
none > 6 cm; or in bilateral or contralateral lymph
nodes, none > 6cm
N2aSingle ipsilateral node > 3 cm but ≤6 cm
N2bMultiple ipsilateral nodes ≤6 cm
N2cBilateral or contralateral nodes ≤ 6 cm
N3: Node > 6 cm.
M = Distant Metastasis
M0No distant metastasis
M1Distant metastasis
Tumor Node Metastasis (TNM) System

To decide whether a tumor is malignant or not, a sample
must be taken by a surgeon or an interventional
radiologist and sent to the laboratory and examined
under a microscope by a pathologist -the sample is
called a biopsy. There are three different types of
biopsies:
1-Excisional biopsy:-the entire lump or suspicious area is
surgically removed
2-Incisional (core) biopsy:-a sample is surgically
removed from the tumor
3-Needle aspiration biopsy:-fluid or a sample of tissue is
removed with a needle
Tumor Stage Grouping
TNM ClassificationStage
M0N0TisStage 0
M0N0T1Stage I
M0N0T2Stage II
M0N0T3Stage III
M0N1T1, T2, T3
M0N0T4aStage IV A
M0N1T4
M0N2T1, T2, T3,
T4a
M0N3Any TStage IV B
M0Any N T4b
M1Any N Any T Stage IV C

Include those in which no infection is present; only
skin microflora potentially contaminate the
wound, and no hollow viscous that contains
microbes is entered.
Example: Hernia repair, biopsy specimen from
skin.
Clean wounds
(class I)
Include those in which a hollow viscous such as
the respiratory, alimentary, or genitourinary tracts
with Indigenous bacterial flora is opened.
Example: Cholecystectomy, elective oral surgery.
Clean/
contaminated
wounds
(class II)
Include open accidental wounds encountered
early after injury, those with extensive
introduction of bacteria into a normally sterile
areaof the body due to major breaks in sterile
technique.
Example: Penetrating abdominal trauma, large
tissue injury.
Contaminated
wounds
(class III)
Include traumatic wounds in which a significant
delay in treatment has occurred and in which
necrotic tissue is present.
Example: necrotizing soft tissue infections
Dirty wounds
(class IV)
Surgical wounds are classified based on the bacterial
load at the time of surgery:
1.Clean wounds (class I)
2.Clean/contaminate wounds (class II)
3.Contaminated wounds (class III)
4.Dirty wounds (class IV)
8Surgical wound & Infection

Suture wound closes immediately
(a.k.a. “first intention”)
Wound is left open and heals over
time without sutures (“secondary
intention”); it heals by granulation,
contraction, and epithelialization
over weeks (leaves a larger scar)
Primary wound closure
Secondary wound closure
* Infections of the tissues, organs, or spaces exposed by
surgeons during performance of an invasive procedure.
* SSIs are classified into:
-Incisional
1. Superficial (limited to skin and subcutaneous tissue).
2. Deep.
-Organ/Space infections
Surgical Site Infections (SSIs)

1-Number & Virulence of
the organism.
2-Anatomy of the involved
area.
3-Patient Health & Immune
system.
Factors influence the spread of Infection
Patient factors:
Older age
Immunosuppression
Obesity
Diabetes mellitus
Chronic inflammatory
process
Malnutrition
Smoking
Renal failure
Peripheral vascular
disease
Anemia
Radiation
Local factors:
Open compared to
laparoscopic surgery
Poor skin preparation
Contamination of
instruments
Inadequate antibiotic
prophylaxis
Prolonged procedure
Local tissue necrosis
Blood transfusion
Hypoxia, hypothermia
Microbial factors:
Prolonged
hospitalization (leading
to nosocomial
organisms)
Toxin secretion
Resistance to clearance
(e.g., capsule formation)
Risk factors for development of surgical site infections

FourStagesofInfection
InoculationCellulitisAbscess Resolution
1. Prophylactic antibiotic given at time of induction of
anasthesia
2. Wound swab for culture and sensitivity
3. Incision and drainage of abscess collection
4. Antibiotic therapy (paranteral, oral and some times
topical antibiotic)
5. Daily two time change dressings
6. Wound debridement then closed the wound.
7. Open wounds some times are allowed to heal by
secondary intension.
Treatment

Wound healing is a complex cellular and biochemical
cascade that leads to restitution of integrity and
function.
9Wound healing
Hemostasis and Inflammation (0-6 days).
Proliferation (4-14 days).
Maturation and Remodeling.
Epithelialization.
Stages of healing
Classification of wound
1. Acute wound2. Chronic wounds
Heal in predictable time and manner and is well -healed
wound.
Managing the acute wound
1-Cleansing, washingby normal saline fluid.
2-Diagnosisfor any damaged organ or tissue.
3-Surgical debridement.
4-Repair of structures like arteries, veins, nerves.
5-Replacement of lost tissues where indicated like bone
graftand vascular graft.
6-Skin coverif required.
7-Skin closure without tension.
1. Acute wound

Classification of wound closure and healing
1. Primary Intention: An incised wound that is cleanand
closed by sutures.
2. SeccondaryIntention: bacterial contamination or
tissue loss, a wound will be left open to heal by
granulation tissue formation.
3-Tertiary Intention: Delayed primary closure, or healing
by tertiary intention, represents a combination of the
first two, consisting of the placement of sutures, allowing
the wound to stay open for a few days, and the
subsequent closure of the sutures.
Factors influencing healing of a wound
Local Factors
1-Siteof the wound.
2-Structuresinvolved.
3-Contamination(foreign bodies/bacteria).
4-Loss of tissue.
5-Vascular insufficiency(arterial or venous).
6-Radiation.
Systemic factor
1-Malnutritionor vitamin and mineral deficiencies.
2-Disease(e.g. diabetes mellitus).
3-Medications(e.g. steroids).
4-Immune deficiencies(e.g. chemotherapy, Acquired
Immunodeficiency Syndrome (AIDS)).

Wounds that have failed to proceed through the orderly
process that produces satisfactory anatomic and
functional integrity or that have proceeded through the
repair process without producing an adequate anatomic
and functional result.
The majority of wounds that have not healed in 3
monthsare considered chronic.
Malignant transformation of chronic ulcers can occur in
any long-standing wound (Marjolin’sulcer). cancers
arising in chronic wounds include both squamous and
basal cell carcinomas.
Types of Chronic Wounds
Ischemic Arterial Ulcers
These wounds occur due to a lack of blood supply and
are painfulat presentation, rest pain, night pain, and
color or trophic changes
Venous Stasis Ulcers
Venous ulcers are due to venous stasis and hydrostatic
back pressure
Causes; Varicose Vein and Chronic Venous Insufficiency
Diabetic Wounds (diabetic foot)
10% to 25% of diabetic patients run the risk of
developing ulcers.
The major contributors to the formation of diabetic
ulcers include neuropathy and ischemia.
2. Chronic wound

An overabundance of
fibroplasia in the dermal
healing process.
Rise above the skin level but
stay within the confines of the
original woundand often
regress over time.
Usually develop within 4 weeks
after trauma.
Excess healing
Hypertrophic Scars
Overabundance of fibroplasia in
the dermal healing process.
Keloids rise above the skin level
as well, but extend beyond the
border of the original wound
and rarely regress
spontaneously.
Tend to occur 3 months to
years after the initial insult.
Keloids

Where scars cross joints or
flexion creases, a tight web may
form restrictingthe range of
movement at the joint.
Treatment
-Z-plasties, or flapsintensive
-physiotherapyare often
required postoperatively.
Contractures
Treatment of hypertrophic and keloid scars
1-Silicone gel sheeting (mechanism unknown).
2-Intralesionalsteroid injection.
3-Excisionand steroidinjections.
4-Excisionand postoperative radiation.
5-Laser–to reduce redness (which may resolve in any
event).
6-Intralesionalexcision (keloids only).

10OroantralFistula
Anatomy of the nose & paranasal sinuses
* The paranasal
sinuses are found in
the interior of
maxilla, frontal,
sphenoid, and
ethmoid bones.
* They are lined with
mucoperiosteumand
filled with air.
* They communicate
with the nasal cavity
through relatively
small apertures.
External Nose THE PARANASAL
SINUSES
The nasal cavity has:
-A floor.
-A roof.
-A lateral wall.
-A medial or septal wall.
Nasal Cavity

* Extraction:-upper 1
st
& 2
nd
molar and 2
nd
premolar
(diverge roots , little bone between roots and sinus).
* Maxillary sinus surgery.
* Malignancy.
* Osteomyelitis.
* Radiation therapy.
* Trauma.
* Syphilis.
* Dental Implant.
Fistula: Is a
connection
between two
epithelial
lined surfaces.
Oroantralfistula Oroantralcommunication
is an epithelial lined tract
between oral cavity and the
maxillary sinus
anabnormal connection
between oral cavity and
maxillary sinus
after 48 hrsbefor48 hrs
Etiology

* Diagnosis.
* Inform the patient .
* Definitive treatment.
* Follow up for several weeks.
Management
Diagnosis
Clinical signs and symptoms
Cotton test (placed under OAF and apply
gentle Valsalva, it ii deflected by air steam)
Radiographic imaging
Blowing test (gentle valsalva)
Mirror fog test (place the mirror under
OAF, if there is no fog or hissing sound,
there is no OAF).
Management goals
To protect the
sinus from oral
microbial flora.
To prevent
escape of
fluids.
To treat
existing antral
pathology.

Clinical signs and symptoms
EARLY -
ACUTE
Air bubbles through the tract
when the patient attempts to
blow out against a closed nose.
Nasal regurgitation of liquid
Unilateral epistaxis
Altered vocal resonance
Pain
LATE –
CHRONIC
(14 DAYS)
Polyp through the extraction
socket
Unilateral nasal and post nasal
discharge
Bad taste in the mouth
Pain , fever, headache
sinusitis
Radiographic imaging
Intra oral
PA.
CT
(coronal
view).
OPG Occipitomental
(OM) view: (Sinus
floor discontinuity,
sinus opacity).

Management
within 24hrs
(Oroantral
communication)
Small < 3mm.
* May heal spontaneously.
* Sinus precautions: {Avoid nose
blowing, Prescribe antibiotics,
Local decongestant (Ephedrine
drops, Inhalations menthol),
Analgesics, Antihistamine, Avoid
direct brushing}
3mm –6mm.
* The edges clean.
* Close immediately under LA: Fig.
8 & horizontal mattress suture.
* Sinus precautions.
Larger than 6mm treated by flaps.
more than 24hrs
defer closure until edges heals . 3
weeks
And eliminate antral infection before
surgery
supportive treatment
-Antibiotics
-Pack (iodoformpack, whitehead`s
varnish).
-Acrylic plate (prevent food entry to
antrum)

BUCCAL FLAP
PALTAL FLAP
COMBENATION OF BOTH
Buccal fat pad
Tongue flap
Alloplastic material
Bone graft
Surgical procedures
Preoperative (extraction) radiograph.
Surgical extraction and roots section.
Avoid excessive apical pressure.
*(do not probe through the socket into the sinus
May perforate the lining , introduce foreign material
including bacteria which may complicate the situation)
PRINCEPLES
Free end of flap should have adequate blood supply.
Suture line well supported by sound bone.
Flap should be done with no tension .
Antral lavage . intranasnalantrostomy, caldwell-luc
Bone graft
When bony defect not enough to support flaps
And in failed cases.
Options:
Chin
Retro molar area
Iliac crest
Prevention

Escape of blood out side the
circulatory system. The hemorrhage
is synonymous with bleeding.
Any damage to the vasculature
leading to out flow of blood. Loss of
blood due to any reason beyond a
certain point is potentially life
threatening and may lead to death.
11Hemorrhage
Classification
Classfication
Source
Arterial
Venous
Capillary
Timing
Primary
Reactionary
Secondary
Nature
External or revealed
Internal or cncealed
Duration
Acute
Chronic

1. SOURCE
SOURCE-
CAPILLARY
SOURCE-
VENOUS
SOURCE-
ARTERIAL
Bright red.Darker red.
Color become
further darker
with oxygen
desaturation.
Bright red.
Rapidand oozing.Steady and
copious flow.
Emitted as
spurting jet
with each heart
beat.
Generally minor
and easy to
control.
Blood loss
becomes serious if
continues for
hours.
Usually easy to
control.
Often hard to
control
Can lead to
sever blood
loss.

2. TIMING
SECONDARYREACTIONARYPRIMARY
Occurs after 7-14
daysof surgery
Bleeding within
24 hrs(usually
4-6 hrs) of
surgery
Occurs at time
of surgery
Cause is sloughing
of vessel due to
infection , pressure
necrosis or
malignancy
Cause slipping
of ligature ,
dislodgement of
clot , or
cessation of
reflex
vasospasm
Cause is injury
to the vessels.
May be
arterial, venous
or capillary
First a warming
small amount
blood stain
followed by a
sudden sever bleed
Common after
hemorrhoids
surgery , GI surgery
and amputations
Bleed starts
when there is
arise in the
arterial or
venous pressure
More common
in the surgery
of
malignancies

3. NATURE
INTERNAL HEMORRHAGE
OR CNCEALED
EXTERNAL
HEMORRHAGE OR
REVEALED
Internal or invisible bleed –
blunt or penetrating
trauma
External or visible bleed –
soft tissue injury
May remain concealed as
in ruptured spleen or liver
Bleeding from the limb
vessels , wound , nose …
etc
Concealed hemorrhage
may become revealed as in
haematemesisor malaena
in peptic ulcer bleed
4. DURATION
CHRONICACUTE
Slowbleeding, smallin
quantity.
Massivebleeding.
for long time.in short time.
like in small amount GI
bleeding
like in arterial injury or
esophageal variceal
bleeding due to portal
hypertension

1. Trauma.
2. Infections.
3. Congenital malformations.
4. Surgical (intra operative /postoperative).
5. Systemic diseases (viral infection, scurvy, allergy).
6. Abnormalities in clotting factors (hemophilia A,
multiple myeloma).
7. Abnormalities in platelets (leukemia, Idiopathic
Thrombocytopenic purpura (ITP)).
Etiology
Mechanism of cessation of extravasations of blood.
Four important steps:
A. Vascular spasm, injured blood vessels undergoes
constriction due to spasm.
B. Formation of platelet plugthis lead to primary
homeostasis.
C. Formation of blood clotas a result of blood
coagulation leading to completion of secondary
homeostasis.
D. Fibrous organization of clot or retraction of clot.
HEMOSTASIS

PRIMARY HEMOSTASIS
Process of platelet plug formation at the site of injury.
Occurs within seconds of injury and is important for
stoppage of blood from arterioles , venulesand
capillaries.
There is platelet adhesion, release of granules and
platelet aggregation resulting in formation of primary
haemostaticplug.

Historyand physical examination provides valuable clues.
* History should include following questions:
-Is there any personal or family history of bleeding
tendency.
-Past surgical history.
-History of hematuria, epistaxix, GIT bleeding.
-Drug history.
* Examination of liver and spleen.
* Examination of skin and mucosal surfaces.
CLINICAL EVALUATION
SECONDARY HEMOSTASIS
Activation of clotting process in plasma that results in
formation of fibrin which strengthens the primary
haemostaticplug. Completed in several minutes and
is important in bleeding from larger vessels.
Some substances promotes clotting (procoagulants)
and some prevent clotting (anticoagulants).
There is complex interaction of various factors of
coagulation in the formation of clot.

Bleeding Time (BT)
* BT > 10 min have increased risk of bleeding.
* BT is prolonged in:
-Thrombocytopnea.
-Von –Willbrandsdisease.
-Platelets dysfunction.
Platelet Count (BC)
* Normal range 1500000 –4500000 / ml of blood.
* When count become 50000 -100000 / ml there is mild
prolongation of BT so that bleeding occur after sever
trauma or surgery.
* Less than 50000 / mlthere is easy bruising manifests as
bruisingand echymosesafter trauma.
* If < 20000 / ml leads to spontaneous bleeding like
intracranial or any other internal bleeding
ProthrombineTime (PT)
* NormalPT is usually 12-14 seconds.
* Prolongedin patients on warferinanticoagulant
therapy, vitamin K deficiency, deficeincyof factor V, VII,
X, prothrombin or fibrinogen.
Partial Thromboplastin Time (PTT)
* Prolonged in hemophilic patients.
* Normal PTT < 45 seconds.
* Small change in PTT may be of great significant.
Laboratory tests

METHODS OF ACHIEVING HEMSTASIS
Methods of achieving
hemstasis
Mechanical
methods
Pressure
Tourinquet
Haemostat
Sutures & ligation
Chemical
methods
Adrenaline
Thrombin
Surgicel
Gelatinesponge or gelfoam
or surgifoam
Bone wax
Thermal
methods
Electrocautery
Cryotherapy
Laser
Systemic
agents
Whole blood
Platelet rich plasma
Fresh frozen plasma

1. PRESSURE
* Immediate measure for capillary or venous bleeding.
* Firm pressure should applied over the bleeding site
using either finger or gauze for at least 5 minutes.
* This would control most of hemorrhages by
counteracting the hydrostatic pressure of the bleeding
vessel.
MECHANICAL METHODS
2. TOURINQUET
An extremity tourniquet that
occludes a major vessel
proximal to the bleeding site.
3. HAEMOSTAT
plication of haemostatat the
bleeding point helps indirect
occlusion of the bleeding
vessel.
4. SUTURES & LIGATION
* Several blood vessels may be
tied with ligatures, a ligature
replaces the hemostat as a
permanent method of
homeostasis.
* For large pulsating artery a
trans fixation suture to prevent
slipping is indicated.

1. ADRENALINE
* Topical application of adrenaline
brings about vasoconstriction of
bleeding capillaries.
* Available in ampoule which is
applied by gauze.
* Concentration of 1 in 1000 is used
for homeostasis over the oozing site.
CHEMICAL METHODS/ LOCAL AGENTS
2. THROMBIN
Helps in converting the fibrinogen
into fibrous clot.
3. SURGICEL
* Oxidized cellulose polymer
obtained by dissolving pure alpha
cellulose in alkaline solution.
* Acts by forming acid products from
partial dissolution that coagulates
the plasma proteins to form brown
sticky gelatinous clot.
* Applied surgicelresorbs from the
site in 4-8 weeks.
* Disadvantage is that the surgicel
clot is not formed by normal
physiological mechanism.

CHEMICAL METHODS/ LOCAL AGENTS
4. GELATINE SPONGE or
GELFOAM or SURGIFOAM
* Formed from purified pork
skin gelatin.
* Completely absorbable
material.
* Has capacity to absorb 45
times its weight in blood.
* Resorbs completely in 4-6
weeks.
5. BONE WAX
* Sterilized non absorbablemix
of waxes.
* Bone wax is softened with
the fingersto desired
consistency and then applied
over the bleeding site.
* Its haemostaticmechanism
through mechanical
obstruction of the osseous
cavity containing the bleeding
vessel.

Heat achieves homeostasis by denaturation of proteins
1. ELECTROCAUTERY
* Most widely used, which can be applied directly to
bleeding point.
* Cautery point is touched to the hemostat causing
sealing of vessel through action of heat.
* Causes tissue destruction producing burning smell and
smoke during application.
* Effective and convenient way of controlling
hemorrhage.
2. CRYOTHERAPY
3. LASER
THERMAL METHODS

1. WHOLE BLOOD
* Fresh whole blood refers to blood that is administered
within 24 hrsof its donation.
* Whole blood transfusion indicated when there is
excessive blood loss.
* Contains all factors for coagulation.
* Must be checked for HIV, hepatitis B and C viruses.
2. PLATELET RICH PLASMA
* Platelets can be collected from donated whole blood.
* Platelets concentrates are viable for 3 days when
stored at room temp.
* Must be infused quickly via short intravenous
transfusion set.
* One unit rises platelet count by approximately 7000-
10000 /ml.
3. FRESH FROZEN PLASMA
* Unit of fresh frozen plasma is collected from one donor
and contains all coagulation factors.
* Stored at -30 °C should be infused within 2 hrsonce
defrosted.
* It is used to treat conditions in which there are
lowblood clotting factors (INR>1.5) or low levels of
otherblood proteins.
* It is also used as part ofplasma exchange.
SYSTEMIC AGENTS

General anesthesia (GA)
Is the state produced when a patient receives
medications for:
Amnesia
Analgesia
Muscle paralysis
Sedation
An anesthetized patient is in a controlled, reversiblestate
of unconsciousness. Anesthesia enables a patient to
tolerate surgical procedures.
12General Anaesthesia(GA)
The combination of anesthetic agents used for general
anesthesia often leaves a patient with the following
clinical constellation:
1. No response even secondary to painful stimuli
2. Unable to remember what happened (amnesia)
3. Unable to maintain adequate airway protection
and/or spontaneous ventilation as a result of muscle
paralysis
4. Cardiovascular changessecondary to
stimulant/depressant effects of anesthetic agents

-Anesthetist reviews medical records and/or interviews
the patient to determine the best combination of drugs
and dosages and the degree ofmonitoringwill be
required to ensure a safe and effective procedure.
-Key factors in this evaluation are the patient's age,body
mass index (BMI),medical and surgical history, current
medications, and fasting time.
-Assessment of the patient'sairway, involving inspection
of the mouth opening and visualization of the soft
tissues of thepharynx. The condition of teeth and
location ofdental crownsare checked, and neck
flexibility and head extension are observed.
Premedication
-Premedication is the first stage of GA
-This stage, which is usually done in the surgical ward or
in a preoperative holding area, early in the days of
anesthesia
-The goal of premedication is to have the patient arrive
in the operating room in a calm and relaxed
-The most commonly used premedication is midazolam,
a short-acting benzodiazepine
Preanaestheticevaluation
Process of Anesthesia

Induction
-The patient is ready for induction of GA, a critical part
of the anesthesia process. GA is usually induced
commonly in anoperating theatreor in a dedicated
anesthetic room adjacent to the theatre.
-Anaestheticagents may be administered by various
routes, includinginhalation, injection(intravenous
(IV),intramuscular (IM), orsubcutaneous (SC))
-Commonly used intravenous (IV) induction agents
includepropofol,sodium thiopental,etomidate,
andketamine
-Inhalational anaesthesiamay be chosen when
intravenous access is difficult to obtain (e.g., children),
when difficulty maintaining the airway is anticipated, or
when the patient prefers it.Sevofluraneis the most
commonly used agent for inhalational induction
Maintenance
The duration of action of intravenous induction agents is
generally 5 to 10 minutes, after which time spontaneous
recovery of consciousness will occur. In order to prolong
unconsciousness for the required duration (usually the
duration of surgery), anaesthesiamust be maintained.
This is achieved by allowing the patient to breathe a
carefully controlled mixture of oxygen,nitrous oxide, and
halothane , isofloraneor sevoflorane, or by intravenous
anaesthetics, such asopioids(usuallyfentanylor a
fentanyl derivative) andsedatives(usually propofolor
midazolam)

-At the end of surgery, the anaestheticagents are
discontinued. Recoveryof consciousness occurs when
the concentration of anaestheticin the brain drops
below a certain level (usually within 1 to 30 minutes,
depending on the duration of surgery).
Severalmonitoringtechnologies allow for a controlled
induction and maintenance of GA
1. Continuouselectrocardiography(ECG):Electrodesare
placed on the patient's skin to monitor heart rate and
rhythm.
2. Continuouspulse oximetry(SpO2): A device is placed,
usually on a finger, to allow for early detection of a fall in
a patient'shaemoglobinsaturation with oxygen.
3. Blood pressure monitoring: There are two methods:
-non-invasive blood pressure (NIBP) monitoring.
This involves placing ablood pressure cuffaround
the patient's arm, forearm, or leg
-invasive blood pressure (IBP) monitoring. This
method is reserved for patients with significant heart
or lung disease, the critically ill , It involves placing a
special type of plasticcannulain an artery, usually in
the wrist (radial artery) or groin (femoral artery).
Physiologic monitoring

4. Agent concentration measurementanaesthetic
machinestypically have monitors to measure the
percentage of inhalational anaestheticagents used as
well as exhalation concentrations. These monitors
include measuringoxygen,carbon dioxide,
andinhalational anaesthetics(e.g.,nitrous
oxide,isoflurane).
5. Capnographymeasures the amount ofcarbon
dioxideexhaled by the patient allowing the
anesthesiologist to assess the adequacy of ventilation.
6. Electroencephalography (EEG) used to verify the depth
of anaesthesia. This reduces the likelihood ofanesthesia
awarenessand of overdose.
-Anaesthetized patients lose protective airway reflexes
(such ascoughing),airway patency, and sometimes a
regular breathing pattern due to the effects of
anaesthetics,opioids, ormuscle relaxants
-To maintain an open airway and regulate breathing ,
mechanical ventilation, anendotracheal tube
or laryngeal mask airways.
Airway management
laryngoscope
with a standard
blade
Endotracheal
tubes
The laryngeal
mask airway
Fibrotic
incubating
bronchoscope

-Muscle relaxation allows surgery within majorbody
cavities, such as theabdomenandthorax, without the
need for very deep anaesthesia, and also
facilitatesendotracheal intubation
-Acetylcholine, the naturalneurotransmitterat
theneuromuscular junction, causes muscles to contract
when it is released from nerve endings. Muscle relaxants
work by preventing acetylcholine from attaching to its
receptor. Paralysis of the muscles of respiration
thediaphragmandintercostal musclesof the chest
requires that some form of artificial respiration be
implemented. Because the muscles of thelarynxare also
paralysed, the airway usually needs to be protected by
means of anendotracheal tube.
-The effects of muscle relaxants are commonlyreversed
at the end of surgery byanticholinesterasedrugs.
-Examples of skeletal muscle relaxants in use today are:
* Pancuronium
* Rocuronium
* Vecuronium
* Atracurium
* Mivacurium
* succinylcholine
Neuromuscular blockade

-Anaesthesiashould conclude with a pain-free
awakening and a management plan for postoperative
pain relief.
-This may be in the form ofregional analgesiaor
oral,transdermal, orparenteralmedication.
-Minor surgical procedures are amenable to oral pain
relief medications such as paracetamoland NSAIDs
(e.g.,ibuprofen).
-Moderate surgical procedures require the addition of
mildopiatessuch astramadol
-Major surgical procedures may require a combination of
modalities to confer adequate pain relief. Parenteral
methods include patient-controlled analgesia (PCA)
involving a strong opiate such asmorphine or fentanyl ,
The patient presses a button to activate a syringe device
and receive a preset dose or "bolus" of the drug (e.g.,
one milligram of morphine).
Postoperative care
Anaesthetic
machine

Fluid constitutes approximately 50% to 60% of total body
weight. It is influenced by different factors. Gender, age
and body composition affect this percentage.
In general, women have a lower body fluid percentage
than men. This is because women have more tissue than
men. The ideal percentage for adult women will
fluctuate between 45 and 60%, while the ideal
percentage for adult men will be between 50 and 65% of
the total body. For the real athletic body types it is even
recommended to have 5% more body water than the
average adult range.
The fluids of the body are primarily composed of water,
which in turn contains a multitude of substances. One
such group of substances includes electrolytessuch as
sodium, potassium, magnesium, phosphate, chloride,
etc. Another group includes metabolites, such as oxygen,
carbon dioxide, glucose, urea, etc. A third important
group of substances contained within the water of our
body, which includes proteins, most of which are vital for
existence. Examples of proteins include coagulation
factors, immunoglobulins, albumin, and various
hormones.
13Fluid and Electrolyte
Management of the Surgical Patient
Total Body fluid

As the distribution of the fluid in the body and the
substances found within is critical for the maintenance of
intracellular and extracellular functions pivotal to
survival, the body has developed mechanisms to control
compartment composition tightly.
The body's fluid separates into two main compartments:
1. Intracellular fluid volume (ICFV) about 60-70% of total
body fluid.
2. Extracellular fluid volume (ECFV): About one third of
total body fluid, The ECFV is comprised of two spaces:
A. The interstitial fluid volume (ISFV) 75%
B. Plasma volume (PV) 25%
The body's fluid
Intracellular fluid
volume (ICFV): 60-70%
of total body fluid
Extracellular fluid
volume (ECFV): one
third of total body fluid
The interstitial
fluid volume
(ISFV) 75%
Plasma volume
(PV) 25%

The ECF compartment is balanced between sodium,
the principal cation, and chloride and bicarbonate,
the principal anions
The intracellular fluid compartment is composed
primarily of the cations potassium and magnesium,
and the anions phosphate and sulfate, and proteins
The concentration gradient between compartments is
maintained by adenosine triphosphate–driven
sodium-potassium pumps located with in the cell
membranes
Proteins add to the osmolality of the plasma and
contribute to the balance of forces that determine
fluid balance across the capillary endothelium
Composition of Fluid Compartments

The movement of water across a cell membrane
depends primarily on osmosis.
To achieve osmotic equilibrium, water moves across a
semipermeable membrane to equalize the
concentration on both sides.
This movement is determined by the concentration of
the solutes on each side of the membrane.
Osmotic pressure is measured in units of osmoles
(osm) or milliosmoles (mOsm) that refer to the actual
number of osmotically active particles. For example, 1
mmolof sodium chloride contributes to 2 mOsm(one
from sodium and one from chloride).
OsmoticPressure
Healthy person consumesan average of 2000 mL of
water per day. approximately 75% from oral intake
and the rest extracted from solid foods.
Daily water lossesinclude 800 to 1200 mL in urine,
250 mL in stool, and 600 mL in insensible losses;
Insensible losses of water occur through both the skin
(75%) and lungs (25%) and can be increased by such
factors as fever, hypermetabolism, and
hyperventilation.
Normal Exchange of Fluid and Electrolytes

Disorders in fluid balance may be classified into three
general categories: disturbances in
Volume
Concentration
Composition
Body Fluid Changes
Extracellular volume deficit
Is the most common fluid disorder in surgical
patients.
Causesinclude bleeding, vomiting, diarrhea,
excessive sweating, decreased or inadequatefluid
intake, burns, diuretic use, and kidney failure.
Clinical features:tachycardia, hypotension,
oliguria decrease in skin turgor, dry mucous
membranes sunken eyes and confusion.
Treatedby replacement of fluid and electrolytes.
Extracellular volume excess
Secondary to renal dysfunction, congestive heart
failure, pregnancy or liver cirrhosis.
Signs and symptoms are headache, high blood
pressure, GIT upset, pitting edema, ascites and
dyspnea.
Treatment toward the underlying cause plus
diuretic medication to increase urination.
Disturbances in Fluid Balance (volume)

Volume changes are sensed by both osmoreceptors
andbaroreceptors.
Osmoreceptorsare specialized sensors that classified
into central and peripheral based on their location;
The central receptors are primarily present in the
anterior hypothalamus and the peripheral receptors
which are present within the upper gastrointestinal
tract and portal venous system.They detect even
small changes in fluid osmolality and drive changes in
thirst and diuresis through the kidneys, For example,
when plasma osmolality is increased, thirst is
stimulated and water consumption increases.
Baroreceptorsalso modulate volume in response to
changes in pressure and circulating volume through
specialized pressure sensors located in the aortic arch
and carotid sinuses.
Baroreceptor responses are both neural, through
sympathetic and parasympathetic pathways, and
hormonal, through substances including renin-
angiotensin, aldosterone, atrial natriuretic peptide,
and renal prostaglandins.
The net result of alterations in renal sodium excretion
and free water reabsorption is restoration of volume
to the normal state
Volume Control

Changes in serum sodium concentration are inversely
proportional to TBW
A low serum sodium level occurs when there is an
excess of extracellular water relative to sodium or
sodium depletion.
Causes:
Excessive oral water intake
Iatrogenic intravenous (IV) excess free water
administration.
Postoperative increased secretion of antidiuretic
hormone (ADH) which increases reabsorption of free
water from the kidneys.
Drugs can cause water retention and subsequent
hyponatremia, such as the antipsychotics, tricyclic
antidepressants and angiotensin-converting enzyme
inhibitors.
Decreased sodium intake, such as consumption of a
low-sodium diet or use of enteral feeds.
GI losses from vomiting prolonged nasogastric
suctioning, or diarrhea.
Renal losses due to diuretic use or primary renal
disease.
Signs and Symptoms:Headache, confusion, seizures,
coma, weakness, fatigue, nausea, vomiting and oliguria.
Concentration Changes
Hypornatremia

Results from either a loss of free water or a gain of
sodium in excess of water.
Causes:
Iatrogenic administration of sodium-containing fluids,
including sodium bicarbonate.
Mineralocorticoid excess as seen in
hyperaldosteronism, cushing’ssyndrome, and
congenital adrenal hyperplasia.
Renal causes, including diabetes insipidus, diuretic
use, and renal disease.
Water loss from the GI tract or skin.
Symptomsare rare until the serum sodium
concentration exceeds 160 mEq/L:
Central nervous system: Restlessness, lethargy, ataxia,
irritability, tonic spasms, seizures, coma.
Musculoskeletal; Weakness.
Cardiovascular; Tachycardia, hypotension, syncope.
Tissue; Dry sticky mucous membranes, red swollen
tongue, decreased saliva and tears.
Renal; Oliguria.
Hypernatremia

1. Potassium Abnormalities: Hyperkalemia
&Hypokalemia.
2. Calcium Abnormalities: Hypercalcemia &
Hypocalcemia.
3. Phosphorus Abnormalities: Hyperphosphatemia &
Hypophosphatemia.
4. Magnesium Abnormalities:Hypermagnesemia&
Hypomagnesemia.
Composition Changes
Is defined as a serum potassium concentration above the
normal range of 3.5 to 5.0 mEq/L.
Causes:
-Increased intake:
Potassium supplementation.
Blood transfusions.
Endogenous load/destruction: hemolysis,
rhabdomyolysis, crush injury, gastrointestinal
hemorrhage
-Increased release:
Acidosis & Rapid rise of extracellular osmolality
(hyperglycemia or mannitol)
-Impaired excretion: Potassium-sparing diuretics &
Renal insufficiency/failure.
Hyperkalemia

Is much more common than hyperkalemia in the surgical
patient
Causes:
-Inadequate intake: Dietary, potassium-free
intravenous fluids, potassium deficient TPN
-Excessive potassium excretion: Hyperaldosteronism,
Medications.
-GI losses:
Direct loss of potassium from GI fluid (diarrhea)
Renal loss of potassium (to conserve sodium in
response to gastric losses)
Symptoms and Signs:
GI; constipation .
Neuromuscular; Decreased reflexes, fatigue,
weakness, paralysis.
Cardiovascular; Arrest.
Hypokalemia
Symptoms and Signs:
GI; include nausea, vomiting, intestinal colic, and
diarrhea.
Neuromuscular; symptoms range from weakness to
ascending paralysis to respiratory failure.
Early cardiovascular signs; (ECG) changes (high peaked
T waves) and eventually lead to hemodynamic
symptoms of arrhythmia and cardiac arrest.

Parenteral nutrition:is a form of nutritional support
given completely via the bloodstream, intravenously
with an IV pump. It administers fluid, proteins,
carbohydrates, vitamins, and minerals. It aims to prevent
and restore nutritional deficits, allowing bowel rest while
supplying adequate caloric intake and essential nutrients
Choice of IV Fluid Types selection depends on:
–Na content.
–Osmolarity.
–pH.
–Amount of free water supplied.
–Need for glucose (calories).
–Anticipated rate of administration.
Both lactated Ringer’s solution and normal saline are
considered isotonic and are useful in replacing GI
losses and correcting extracellular volume deficits
Lactated Ringer’s is slightly hypotonic in that it
contains 130 mEqof lactate
Sodium chloride is mildly hypertonic, containing 154
mEqof sodium that is balanced by 154 mEqof
chloride
Fluid and electrolyte therapy
Parenteral nutrition

Hemodynamic instability during anesthesia is best
avoided by correcting known fluid losses, replacing
ongoing losses, and providing adequate maintenance
fluid therapy preoperatively.
In addition to measured blood loss, major open
abdominal surgeries are associated with continued
extracellular losses in the form of bowel wall edema,
peritoneal fluid, and the wound edema during
surgery. Large soft tissue wounds, complex fractures
with associated soft tissue injury, and burns are all
associated with additional third-space losses that
must be considered in the operating room.
IntraoperativeFluidTherapy
Based on current estimated volume status and
ongoing fluid losses
Correction deficits of pre and intraoperative losses
along with maintenance
In the initial postoperative period, an isotonic solution
should be administered.
Resuscitation should be guided by the restoration of
acceptable vital signs and urine output
After the initial 24 to 48 hours, fluids can be changed
to 5% dextrose in 0.45% saline in patients unable to
tolerate enteral nutrition
If normal renal function and adequate urine output
are present, potassium may be added to the IV fluids
PostoperativeFluidTherapy

Interstitial edema
Impaired cellular metabolism
Poor wound healing
Decreased pulmonary compliance
Heart failure –overload
Delayed return of bowel function
Hemodilution
Riskof Excessfluid

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