Surgical site infection: "SSI"

-Infection arising within 30 days of a surgical procedure at the site of the surgical incision, and within 1 year in the presence of the implant.

Types of SSI

1-Incisional SSI
a-Superficial:
-SSI involving only the skin and subcutaneous tissue of the incision.
b-Deep:
-It involves fascia and muscle layers.

2-Organ/space SSI
-SSI involving any part of the body that is deeper than the fascia or muscle layers.

#Surgery

Important clinical pointers:

Under the setting of infantile obstruction of the gut

Infant with dribbling saliva = esophageal atresia until proven other wise.

Infant with vomitting and a lump =Hypertrophic pyloric stenosis until proven otherwise.

Infant with vomitting and no lump and no salivary dribbling = Duodenal atresia until proven otherwise.

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The commonest position of appendix is retrocaecal (74%),Why?
- This is because during childhood the continous growth of the caecum rotates the appendix behind it how ever it will always remain intraperitoneal.

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Barium enema in intussusception :

Charactaristically shows the Claw sign, here barium contrast enters the large bowel and become faced by the negative shadow of the intussusception mass giving rise to these outlines appearing as a claw, it is found in ileocolic and colocolic types, and it is negative in ileoilial type in presence of competent ileocecal valve which blocks the flow of barium into the small bowel, in such cases CT scan is useful for furthur diagnostic evaluation.

#Surgery

Constipation is one of the cardinal features of intestinal obstruction, but it is not present in :

1)Richter hernia.
2)Gallstone obstruction.
3)Incomplete obstruction.
4)Obstruction due to pelvic abscess.
5)Mesentric vascular occlusion.

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-B&L

Physical findings in intussusception:

1) Abdominal lump, can be palpated in 50% to 60% of cases, this lump is hardened and feel like a sausage, the concavity being towards the umbilicus.

2)Sensation of emptiness in the right iliac fossa, known as the Dance sign, it result from upward inversion of the caecum as a result of invaginating ileum.

3)Rectal examination may reveal blood stained mucus, the so called red currant jelly, it is also possible in extensive ileocolic or colocolic variety, that the apex is palpable, or even protrude through the anus.

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What is the most important aspect to examine in a case of intestinal obstruction?

IT IS VITAL to distinguinsh between strangulated and non strangulated obstruction.

In strangulated obstruction the blood supply to the involved bowel is compromised, this is a surgical emergency and justify early laparotomy.

In non strangulated obstruction the blood supply is not compromised and this can be initially managed conservatively.

-Diagnosing strangulation:

This is ENTIRELY clinical, strangulation is present if :

•There is tenderness and rigidity
In case of intestinal obstruction the presence of any localised tenderness is greatly significant, it is noteworthy that in non strangulated obstruction there may also be tenderness over the area of obstruction, but in strangulated variety there will always be tenderness accompained by rigidity and rebound tenderness.

•Shock
Strangulation causes compromised viability of the bowel wall, this facilitate translocation of the enteric bacteria with systemic exposure, sepsis and shock ensues.

•Pain
The pain of strangulation is very severe, it is differentiated from the usual pain of intestinal obstruction itself, by the fact that this pain is never incomplete or interrupted by periods of abscence,, this pain is constant and remains so despite conservative management.

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ERCP is the standard diagnostic tool in primary sclerosing cholangitis.

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80% of patients of primary sclerosing cholangitis have ulcerative colitis.Only 4% of patients of UC may have primary sclerosing cholangitis.

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Thyrotoxicosis factitia:
-Due to consumption of excess thyroxine

Jod Basedow’s thyrotoxicosis:
-Due to excess iodide consumption.

Wolf-Chaikoff effect:
-Iodides given inhibits the thyroxine and leads to hypothyroidism.

#Surgery

Kocher’s:

•Incision- Cholecystectomy
•Test- Obstructed  trachea
•Vein- 4th vein of thyroid
•Kocherization- Mobilization of 1st, 2nd part of duodenum
•Theodor Kocher- Father of thyroid surgery.

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Berry’s:

•Aneurysm- In brain for subarachnoid  hemorrhage.
•Sign– Engulfment of carotid sheath  in malignancy
•Ligament- Condensation of pretracheal fascia in posteromedial compartment
• Picking- Not done now. Picking of involved lymph nodes alone during  surgery in cases of papillary  cancer.

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Note

Situations in which constipation is not present in intestinal obstruction include :

1) Richter's hernia, in which a portion of bowel circumference only is included in the hernial sac.

2) Gallstone obturation, occlusion may be intermittent, as dilatation upstream occur dislodgement may follow.

3) Mesentric vascular occlusion, intestinal obstruction occur due to non-propulsive peristalsis, but diarrhea with bloody stool is also present owing to mucosal infarctions.

4) Incomplete obstruction, e.g Colonic stricture.

5) Intestinal obstruction associated with pelvic abscess, irritation of rectal mucosa yields diarrhea with mucus in stool.

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Possible x ray findings in acute pancreatitis

◼️Sentinel loop sign, represents localised ileus of intestinal loops near the inflamed pancreas.

◼️Generalised paralytic ileus, if inflammation is severe and diffuse, dilated bowel loops will be seen as intestinal obstruction.

◼️Colon cut-off sign, describes a situation in which the colon seems to abruptly "end" as shown in the figure above, it may relate to functional retraction of the phrenicocolic ligament.

◼️Renal halo sign, the inflammatory exudate in the retroperitoneal space seem to enhance the perirenal fat appearing as a radiolucent halo surrounding the kidney, this may occur around both kidneys.

◼️Pleural effusion, may occur as a result of posterior disruption of inflamed pancreatic duct with subsequent formation of a pleuropancreatic fistula.

◼️Calcified radio-opaque gallstone, may point toward gallstone pancreatitis, it has to be noted that only 10% of gallstones are radio-opaque.

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Sure signs of fracture:

1-Deformity.
2-Length discrepancy.
3-Abnormal movement.
4-Crepitus.

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Post-operative return of GI function:

-Small bowel: 12-24h.
-Stomach: 24-48h.
-Large bowel: 48-72h.

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Post-operative History:

History taking:
•Ask about the following points and repeat them every day starting from day 0 (day of operation):
-Fever
-Nausea and vomiting (causes: pain, opioids analgesics, paralytic ileus, and anesthesia).
-Oral intake: solid and liquid.
-Cough/sputum (causes: anesthesia, chest infection).
-Dyspnea.
-Chest pain.
-Pain at site of operation: excessive pain maybe caused by wound infection.
-Wound discharge or bleeding.
-Passage of flatus or stool (indicates the return of GIT function).
-Passage of urine.
-Mobility (i.e. does the patient get up and start walking? prolonged immobility is bad - DVT).
-Pain in the legs (may indicate DVT).
-Tubes & Drains: e.g. Foley catheter, nasogastric tube (NG tube), surgical drain.
-Treatment received: Drugs & IV fluids.

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Cont...

Example of post-operative history:

Day 0:
-The patient had cough, sputum, mild pain at the the site of operation. But there was no fever, no nausea or vomiting, no oral intake, no chest pain, no shortness of breath. She passed urine but hasn't passed flatus or stool. No leg pain & hasn't started mobilizing yet. She received IV fluids & IV medications.

Day 1:
-No fever, no nausea or vomiting, no cough, no chest pain or dyspnea, she passed flatus and stool & oral intake was resumed in the form of liquid & soft food (e.g. orange juice & biscuit). The pain is decreased at the site of operation. The patient started walking in the ward and going to bathroom. She received IV fluids & IV medications.

Day 2:
-No fever, no nausea or vomiting, no cough, no chest pain or shortness of breath, mild pain at operation wound, normal oral intake, normal passage of stool and urine, no leg pain and normal mobility.

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Day 0: It's the day of operation till 12 am.
E.g.,patient has undergone a surgery at 11:00 pm. on Friday, it's called zero day. But when it becomes 12:00 am. Saturday, it became Day 1.

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Suture removal:
-It should be removed within 1-2 weeks depending on anatomical location
1. Face "nose, ear, lip" ➔ 5-7 days
2. Scalp ➔ 7-10 days, neck-7 days.
3. Trunk & upper extremities ➔ 10-14 days
4. Lower extremities ➔ 14-21 days.

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