Comprehensive General Surgery Study Guide

Asepsis and Antisepsis

  • Asepsis (Асептика):

    • Definition: A system of preventive measures designed to completely exclude the entry of microorganisms into a wound, tissues, organs, or the patient’s body during surgical procedures.
    • Core Principle: "No microbes must enter the wound."
    • Key Principles:
      • Sterilization of all instruments, dressings, and sutures.
      • Compulsory use of sterile gloves, gowns, and masks.
      • Isolation of the surgical field using sterile drapes.
      • Maintenance of the sterility of the entire operating room environment.
    • Foundations: Developed significantly under Nikolai Pirogov and later systematized in Soviet surgery by Petrov.

  • Antisepsis (Антисептика):

    • Definition: A set of therapeutic and preventive measures aimed at destroying microorganisms already present in a wound, body tissues, or the patient's body.
    • Core Principle: "Kill microbes that have already entered."
    • Founders: Joseph Lister is recognized as the father of modern antisepsis.
    • Types of Antisepsis:
      1. Mechanical: Includes physical removal through wound debridement.
      2. Physical: Use of drainage systems, hypertonic solutions, or UV light.
      3. Chemical: Use of various antiseptic solutions.
      4. Biological: Utilization of antibiotics, bacteriophages, or immune sera.

Operating Room Cleaning and Air Sterilization

  • Types of Operating Room Cleaning (Уборка операционной):

    1. Preliminary (Предварительная): Performed before the first operation of the day; involves wet cleaning all surfaces and dust removal.
    2. Current (Текущая): Performed during the surgery to remove contaminated materials such as blood or fluids.
    3. Final (Заключительная): Performed after each operation; involves disinfection of tables, instruments, and the floor.
    4. General (Генеральная): Performed weekly; a thorough wash with disinfectants of all surfaces, including walls, ceilings, and lamps.

  • Air Sterilization Methods:

    1. Ultraviolet (UV) Irradiation: Bactericidal lamps used before and after procedures.
    2. Laminar Airflow Systems: Use of HEPA filters to maintain a sterile, unidirectional airflow over the surgical field.
    3. Ventilation Systems: Positive pressure systems designed to prevent the entry of contaminated outside air.
    4. Aerosol Disinfection: Spraying antiseptic solutions into the air.

Wound Infection Pathways and Surgeon Hand Treatment

  • Pathways of Wound Infection:

    1. Exogenous (Экзогенная): Microbes from the external environment.
      • Airborne: Microbes carried in the air.
      • Contact: Direct transmission from hands, instruments, or dressings (most important path).
      • Implantation: Microbes introduced via permanent items like sutures or prostheses.
    2. Endogenous (Эндогенная): Microbes from the patient’s own body (skin flora, internal organ reservoirs, or spread through blood/lymph).

  • Treatment of the Surgeon’s Hands (Обработка рук хирурга):

    • Stages:
      1. Mechanical cleaning: Washing with soap and water for 2−5 min2-5\,\text{min} and cleaning the fingernail area.
      2. Antiseptic treatment: Using agents like Chlorhexidine, Iodine, or alcohol-based solutions.
    • Russian Historical Method: Spasokukotsky-Kochergin method.
    • Modern Standard (WHO-aligned): Alcohol-based hand rubs used 2−32-3 times over the course of 3−5 min3-5\,\text{min}.
    • Core Principle: Hands are never considered truly sterile, only disinfected.

Physical Methods of Sterilization

  • Definition: Destruction of microorganisms using physical factors.
  • Methods:
    1. Steam Sterilization (Autoclaving): The gold standard of sterilization.
      • Temperature: 120−132∘C{120-132}^{\circ}\text{C}.
      • Pressure: 1.1−2 atm1.1-2\,\text{atm}.
      • Time: 20−45 min20-45\,\text{min}.
      • Mechanism: Direct coagulation of microbial proteins.
      • Uses: Instruments, linen, and dressings.
    2. Dry Heat Sterilization:
      • Temperature: 160−180∘C{160-180}^{\circ}\text{C}.
      • Time: 60−120 min60-120\,\text{min}.
      • Uses: Glassware and metal instruments.
    3. Boiling: 100∘C{100}^{\circ}\text{C} for 30−60 min30-60\,\text{min}. Unreliable because it does not kill bacterial spores.
    4. Radiation Sterilization: Use of Gamma rays for industrial sterilization of disposable items.
    5. Ultrasonic Cleaning: Primarily used for pre-sterilization removal of contaminants.

Chemical Methods of Sterilization and Disinfection

  • Gas Sterilization: Using Ethylene oxide for delicate, heat-sensitive instruments; kills spores and viruses.
  • Liquid Chemical Agents:
    1. Hydrogen Peroxide: A strong oxidizing agent.
    2. Glutaraldehyde: A high-level disinfectant used for endoscopes.
    3. Peracetic Acid: Rapid-acting sterilant.
    4. Chlorine Compounds: Primarily used for surface disinfection.
    5. Alcohols (70%70\%): Ethanol or isopropanol used for skin and small instruments.
    6. Iodine Compounds: Used for skin antisepsis.
    7. Phenols: Historically introduced by Joseph Lister.

Processing of the Operative Field (Обработка операционного поля)

  • Definition: Asetpic and antiseptic measures to eliminate microorganisms from the skin at the site of surgery.
  • Stages:
    1. Pre-surgical prep: Hygienic wash and hair removal (clipping is preferred over shaving).
    2. Mechanical cleaning: Soap solution wash to remove sebum and dirt.
    3. Antiseptic treatment: Performed 2−32-3 times using agents like 5−10%5-10\% Iodine, Chlorhexidine, or 70%70\% alcohol.
  • Rules for Application:
    • Treat from the center toward the periphery.
    • Treat from clean areas to dirty areas.
    • Use separate sterile swabs for each pass; never return to the center with the same swab.
    • Creation of a wide sterile zone.

Suture Materials (Шовный материал)

  • By Origin:
    • Natural: Silk, Catgut.
    • Synthetic: Nylon, Vicryl (polyglactin), Prolene (polypropylene).
  • By Absorption:
    • Absorbable: Catgut, Vicryl, Dexon. Used for internal organs and tissues.
    • Non-absorbable: Silk, Nylon, Prolene. Used for skin sutures and vessels.
  • By Structure:
    • Monofilament: Single fiber; lower infection risk.
    • Multifilament: Braided; better handling/knots but higher infection risk due to capillarity.
  • Requirements: Sterility, strength, minimal tissue reaction, and high knot security.

Desmurgy and Dressings (Десмургия)

  • Definition: The study of dressings, application methods, and bandaging techniques.
  • Types of Dressings:
    1. Soft: Gauze bandages.
    2. Hard: Splints and plaster casts.
    3. Occlusive: Airtight; used for chest wounds (open pneumothorax).
    4. Pressure: To achieve hemostasis.
    5. Immobilizing: To fix fractures.
  • Gauze Variations: Swabs (салфетки), tampons (packed into cavities), turundas (narrow strips), balls (шарики for cleaning), and bandages.
  • Standard Bandaging Protocol: Work distal to proximal with moderate tension.
  • Regional Bandages:
    • Head: Cap (чепец), recurrent, or circular.
    • Chest: Spiral or Figure-of-eight.
    • Perineum:* T-shaped.

Wounds (Раны) and Wound Healing

  • Definition: Mechanical tissue damage with disruption of skin or mucous membrane integrity.
  • Classical Signs (Russian School):
    1. Pain (Dolor)
    2. Bleeding (Hemorrhage)
    3. Gaping (Diastasis)
  • Classification:
    • Mechanism: Incised, stab, lacerated, contused, crushed, or gunshot.
    • Contamination: Clean, contaminated, infected.
    • Depth: Superficial, deep, penetrating (into body cavities).
  • Gunshot Wound Zones (Russian Classification):
    1. Wound channel (primary destruction).
    2. Zone of necrosis.
    3. Zone of molecular concussion (reversible damage).
  • Phases of Wound Healing:
    1. Phase I (Inflammation/Exudative): Duration 1−3 days1-3\,\text{days}. Involves vasodilation and leukocyte migration.
    2. Phase II (Regenerative/Proliferative): Duration 3−10 days3-10\,\text{days}. Involves granulation tissue, angiogenesis, and collagen synthesis.
    3. Phase III (Scar Formation/Maturation): Weeks to months. Involves collagen remodeling.
  • Healing Types:
    • Primary Intention: Clean edges, approximated, minimal scar.
    • Secondary Intention: Large defect, infection, healing via granulation and large scar.

Treatment of Wounds and Purulent Process

  • Primary Surgical Debridement (ПХО): Essential mechanical antisepsis; removal of foreign bodies and necrotic tissue.
  • Sutures:
    • Primary: Immediately after treatment (<6−12 hours<6-12\,\text{hours}).
    • Early Secondary: Applied at 5−7 days5-7\,\text{days} once infection is controlled.
    • Late Secondary: Applied after granulation tissue forms.
  • Purulent Wound Management:
    • Rule: "Ubi pus, ibi evacua" (Where there is pus, evacuate it).
    • Drainage: Passive (rubber) or active (vacuum).
    • Hypertonic solutions are used in dressings to draw fluid out.

Bleeding (Кровотечения)

  • Types by Vessel:
    • Arterial: Bright red, spurting, pulsatile; most dangerous.
    • Venous: Dark red, continuous flow.
    • Capillary: Generalized oozing.
    • Parenchymal: From organs (liver/spleen); difficult to control.
  • Severity (by % Circulating Blood Volume - CBV):
    • Grade I (Mild): Up to 10−15%10-15\%.
    • Grade II (Moderate): 15−30%15-30\%.
    • Grade III (Severe): 30−40%30-40\%.
    • Grade IV (Massive): >40%>40\%.
  • Shock Index: Ratio of Pulse / Systolic BP (Normal ≈ 0.50.5; 1.01.0 indicates severe loss).
  • Hemostasis Methods:
    • Temporary: Pressure dressing, tourniquet (limit 1−2 hours1-2\,\text{hours}), digital compression.
    • Final: Vessel ligation, suturing, electrocoagulation, or chemical agents (Thrombin).

Blood Transfusion (Hemotransfusion)

  • Antigen-Antibody Systems:
    • ABO: Discovered by Karl Landsteiner. Antigens (Agglutinogens) on RBCs; Antibodies (Agglutinins) in plasma.
    • Rh Factor (D Antigen): Rh-negative individuals form antibodies only after exposure.
  • Agglutination: The clumping of RBCs when an antigen meets its corresponding antibody. Leads to hemolysis and renal failure.
  • Standard Procedure:
    1. Determine ABO and Rh group (forward and reverse typing).
    2. Phenotyping: Checking minor antigens (Kell, Duffy) for repeated transfusions.
    3. Crossmatch (Major): Donor RBCs + Recipient Serum.
    4. Biological Test (Russian Protocol): Inject 10−15 ml10-15\,\text{ml} of blood, wait 3 min3\,\text{min}, repeat 33 times; monitor for fever, chills, or lumbar pain.
  • Indications: Acute loss of 20−30%20-30\% blood volume, Hb <70 g/L<70\,\text{g/L}.

Anesthesia and Resuscitation

  • Anesthesia Types:
    • General: Loss of consciousness (via Inhalation e.g., Sevoflurane, or IV e.g., Propofol).
    • Local/Regional: Blocking sodium channels (Lidocaine, Novocaine, Bupivacaine).
    • Novocaine Blockades: Vagosympathetic (neck), Paranephric (kidney), Intercostal.
  • Terminal States:
    1. Preagonal state.
    2. Agony.
    3. Clinical Death: Reversible within 4−6 min4-6\,\text{min}. No pulse or breathing.
    4. Biological death: Irreversible.
  • Cardiopulmonary Resuscitation (CPR):
    • Ratio: 3030 compressions to 22 breaths.
    • Compression Depth: 5−6 cm5-6\,\text{cm}; Rate: 100−120/min100-120/min.
    • Defibrillation: Indicated for Ventricular Fibrillation (VF) and Pulseless VT.
    • Duration: Continue for at least 20−30 min20-30\,\text{min}.

Surgical Classifications and Complications

  • Timing: Emergency (immediate), Urgent (hours/days), Planned (elective).
  • Purpose: Radical (cure), Palliative (symptom relief), Diagnostic (biopsy), Prophylactic.
  • Complexity:
    • Simultaneous: Two different diseases treated together.
    • Combined: One disease affecting multiple organs.
  • Infection Level: Clean, Conditionally Clean, Contaminated, Dirty (infected).
  • Surgical Infection Localization:
    • Furuncle: single hair follicle with necrotic core.
    • Carbuncle: several follicles + subcutaneous tissue necrosis.
    • Abscess: Localized pus with capsule.
    • Phlegmon: Diffuse infection (urgent wide incision required).
    • Erysipelas: Streptococcal infection with sharply demarcated red "flame-like" borders.
    • Hydradenitis: Sweat gland infection ("bitch udder"); no necrotic core.

Mastitis and Paraproctitis

  • Mastitis (Inflammation of the Mammary Gland):
    • Stages: Serous $\rightarrow$ Infiltrative $\rightarrow$ Purulent.
    • Etiology: Infection + Lactostasis (milk stasis).
  • Paraproctitis (Inflammation of Pararectal Spaces):
    • Origin: Infection of anal glands.
    • Classification: Subcutaneous, Ischiorectal (most common deep), Pelvirectal (most severe).
    • Chronic form: Rectal Fistula (Intersphincteric, Transsphincteric, or Extrasphincteric).

Finger and Hand Infections (Panaritium)

  • Felon (Panaritium): Purulent infection of finger tissue.
    • Types: Cutaneous, Subcutaneous (pulp), Tendinous (dangerous), Articular, Bone (Osteomyelitis).
    • Signs: "Sleepless night" due to throbbing pain.
  • Hand Phlegmon: Emergency; infection spreads through palmar and thenar spaces.

Traumatology and Specific Conditions

  • Fractures:
    • Absolute Signs: Abnormal mobility, Crepitus, visible fragments.
    • Healing: Primary (direct union) vs. Secondary (callus formation).
    • False Joint (Pseudoarthrosis): Mobile fibrous connection instead of bone.
  • Crash Syndrome (Prolonged Compression Syndrome):
    • Release of compressed muscle leads to myoglobinuria and hyperkalemia.
    • Main danger: Acute Renal Failure.
    • Stages: Early (shock), Intermediate (toxic/anuric), Late.
  • Burns:
    • Degrees: I (epidermis), II (blisters), III (full thickness/necrosis), IV (deep tissues).
    • Rule of Nines: Head (9%9\%), Arm (9%9\%), Leg (18%18\%), Trunk (36%36\%).
    • Burn Disease Phases: Shock, Toxemia, Septicotoxemia, Recovery.
  • Sepsis: Life-threatening systemic response; source control is first priority.
  • Anaerobic Infection (Gas Gangrene): Characterized by gas crepitus, foul smell, and rapid spread. Emergency excision is required.
  • Tetanus: Caused by Clostridium tetani toxin; causes lockjaw (trismus) and opisthotonus; prevented by toxoid and immunoglobulin.

Diagnostics and History Taking

  • Case History (История болезни) Structure: Passport data, Complaints, Anamnesis morbi (present illness), Anamnesis vitae (life/past history), Objective exam, Preliminary diagnosis, Investigations, Final diagnosis, Plan.
  • Physical Exam: Inspection, Palpation, Percussion (density), Auscultation (function).
  • Imaging: X-ray, CT (gold standard for trauma), MRI (soft tissue), Ultrasound (FAST protocol).
  • Pulse Points: Carotid, Brachial, Radial, Femoral, Popliteal, Dorsalis pedis.
  • Lymph Node Assessment: Evaluate size, consistency (hard = malignancy), tenderness (painful = infection), and mobility.