General Surgery – Comprehensive Bullet Notes

Learning Objectives
- Discuss anatomy, pathology, diagnostics, pre-op preparation, instrumentation, equipment, patient preparation, procedure overview, outcomes, post-op care & complications.
Key Suffixes/Roots
- -ectomy: surgical removal
- -otomy: incision/opening
- -ostomy: create passage/opening
- -oscopy: endoscopic examination
Operative Action Verbs
- Anastomosis, appose/approximate, blunt dissection, communicate, divide, excise, exposure, atresia, incise, resect, retract, mobilize

Skin Incisions
- Large: #3 handle + #10 blade
- Small: #3 handle + #15 blade
- Cautery follows blade for subcutaneous tissue

Definition: Protrusion of tissue/organ through fascial defect.
Types
- Reducible – contents manually return
- Irreducible/Incarcerated – cannot reduce
- Strangulated – compromised blood supply
- Congenital vs. Acquired (heavy lifting, cough, obesity, straining)
Diagnostic Tests: Manual palpation, CT, MRI
Pre-op Prep: Shave prep
Common Instruments/Supplies
- Small lap set, synthetic mesh, $0$ Prolene CT, Penrose drain, Ancef irrigation
Anaesthesia: Usually general; epidural possible (inguinal); local + sedation occasionally
Position: Supine; arms tucked/out
Skin Prep: Dura-prep, 6-min, umbilicus→groin
Draping: Cuffed towels, clips/Ioban, plain + lap sheet
Post-op: VS, airway, dressing, fluid output, pain; d/c ~1 h; avoid straining
Complications: Recurrence, nerve injury, infection, hemorrhage, bowel dysfunction

Definition: Groin hernia where abdominal fold meets thigh
Direct
- Defect in transversalis fascia (Hesselbach’s triangle); no sac; acquired; males
Indirect
- Through internal ring, along spermatic cord; most common
Pantaloon – combined direct + indirect
Femoral (below inguinal ligament via femoral ring; females)
Key Anatomy: Inguinal/femoral rings, inferior epigastric vessels, spermatic cord, Cooper’s ligament
Differences
- Direct = triangle; Indirect = ring + cord (Penrose + Kelly to retract cord); Femoral = femoral canal
Special Supplies
- Synthetic mesh, $0$ or $2 ext{-}0$ Prolene, Penrose
Incision: Oblique inguinal
Key Steps
- Divide fascia; mobilize cord; Penrose + Kelly retraction
- Ligate hernia sac; close fascia (interrupted); mesh secured
Closure
- SubQ: $2 ext{-}0$ Vicryl SH
- Skin: Staples or $4 ext{-}0$ Vicryl PS2
Dressing: Telfa, gauze, silk tape ± Mastisol/Steri-strip/Tegaderm

Definition: Hernia at prior incision/stoma; abdominal wall
Instrumentation: Large laparotomy set, Bookwalter retractor
Supplies: Large mesh, $0$ Prolene CT, suture bridges, #5 Tevdek
Incision: Old scar excised (held w/ Allis)
Operative Steps
1. Incise hernia sac, wide fascial clearing
2. Divide adhesions; reduce contents
3. Approximate fascia (undermine if needed)
4. Repair w/ interrupted sutures ± onlay/underlay mesh (double-layer Marlex)
Closure & Dressing: Routine; same dressing as inguinal; may add abdominal binder

Procedures: Biopsy, lumpectomy, simple, modified radical, radical mastectomy
Indications: Prevent/treat breast cancer
Diagnostics: Mammogram, palpation, US, FNA, CT/MRI
Psychosocial: Body-image concerns (all genders)
Position: Supine, operative side near table edge; ipsilateral arm on armboard
Field Management: Biopsy ± mastectomy may require 2 separate sterile fields to prevent tumor seeding; gown/glove change between fields
Post-op Complications: Infection, hemorrhage, seroma

Instrumentation: Small lap or biopsy tray, plastic set, #15 blade
Supplies
- $3 ext{-}0$ Vicryl SH (dead space)
- $4 ext{-}0$ Vicryl PS2 (skin)
Incisions: Curved/elliptical based on tumor location
Procedure: Mobilize mass → remove → send margins to pathologist (frozen section)
Closure: Close subQ; cosmetic skin closure
Dressing: Mastisol, Steri-strips, Tegaderm

Definitions
- Radical – breast + pectoralis minor + nodes
- Modified Radical – breast + nodes (most common)
- Simple – breast only
Instrumentation: Small lap or reconstruction set; hemoclip appliers, plastic set
Supplies: Same sutures as biopsy; ties; bulky dressing; hemoclips; Kittner sponges; drains & JP reservoir; Surgi-bra
Key Steps
1. Elliptical incision; raise flaps
2. Dissect breast, pectoral muscles/nodes per type
3. Irrigate muscle bed w/ sterile water (kills free CA cells)
4. Place drains (15 blade, tonsil for tunnel)
Closure
- SubQ: $2 ext{-}0$ Vicryl SH
- Skin: $4 ext{-}0$ Vicryl PS2
Dressing: Bulky/compressive; Surgi-bra

Definition: Ligation of saphenous vein + tributaries; extraction via stripper; dx = varicose veins
Pathology: Dilated, incompetent valves
Instrumentation: Small lap, Weitlaner, hemoclip appliers, vein stripper
Supplies: Marking pen (incisions), ace bandage (compression), hemoclips
Equipment: Leg holder
Position: Depends on vein segment
Key Steps
1. Mark incisions; prep entire limb
2. Incise at proximal & distal points; ligate tributaries
3. Feed stripper; secure; pull vein out
4. Close wounds
Dressing: Telfa, gauze, ace wrap (must stay to limit edema)
Post-op: Limited mobility; elevate leg; monitor swelling

Mesh Use: Synthetic prosthetics (Marlex, Prolene) for tension-free hernia repairs
Suture Selection:
- Non-absorbable monofilament (Prolene) for fascia/mesh fixation
- Absorbable braided (Vicryl) for subQ & skin, providing strength then resorption
Drains: Penrose for hernia cord retraction; JP for dead-space management in mastectomy
Asepsis: Separate fields when tumor cells present; irrigation w/ bactericidal/sterile water as oncologic measure
Expected Outcomes: Excellent prognosis when defect adequately repaired or malignancy fully excised; typical activity resumption 6-8 weeks (hernia).

Return to normal activity after hernia repair: $6\text{–}8\ \text{weeks}$
Hernia skin prep duration: $6\ \text{minutes}$
Reservoir volume example (JP): $150\ \text{mL}$
Suture sizes: $0$ , $2\text{-}0$ , $3\text{-}0$ , $4\text{-}0$ , #5 Tevdek (≈7 metric)

Body-image & sexuality with breast loss or gynecomastia
Patient education: Avoid heavy lifting post-hernia; compression compliance after vein stripping; drain care post-mastectomy
Informed consent must address recurrence risk, nerve injury, cosmetic outcomes