General surgery at the district hospital edited by John Cook Consultant Surgeon Department of Surgery Eastern General Hospital Edinburgh, Scotland Balu Sankaran Formerly Director Division of Diagnostic, Therapeutic and Rehabilitative Technology World Health Organization Geneva, Switzerland Ambrose E.O. Wasunna Medical Officer Clinical Technology World Health Organization Geneva, Switzerland and Professor of Surgery University of Nairobi Nairobi, Kenya illustrated by Derek Atherton and Elisabetta Sacco World Health Organization Geneva 1988 ISBN 92 4 154235 7 © World Health Organization 1988 Publications of the World Health Organization enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Uni- versal Copyright Convemion. For rights of reproduction or transla· tion of WHO publications, in part or in toto, application should be made to the Offtce of Publications, World Health Organization, Geneva, Switzerland. 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Printed in Swi,zerland 8817648 Alar - 7000 CONTENTS Preface 9 Contributors 10 Introductory note 11 Fundamentals of general surgery 1 Basic principles and techniques 15 Asepsis Preparation for surgery Prevention of transmission of human immunodeficiency virus (HIV) Surgical methods and materials Wound debridement Incision and drainage of abscesses Split-skin grafting 2 Fluid and electrolyte therapy, blood transfusion, and management of shock Fluid and electrolyte therapy Blood transfusion Shock Face and neck 5 3 Primary care of wounds of the face General principles Lip Tongue Ear and nose Cellulitis of the face 4 Eye Basic principles and procedures for eye surgery Ocular trauma Extraocular surgery Intraocular surgery Enudeation of the eye 36 49 53 Contents 5 Ear 72 Removal of foreign bodies Myringotomy Acute mastoiditis with abscess 6 Nose 76 Control of epistaxis Removal of foreign bodies 7 Teeth and jaws 78 Extraction of teeth The barrel bandage Fractures of the jaw 8 Throat 84 Incision and drainage of peritonsillar abscess Incision and drainage of retropharyngeal abscess Incision and drainage of acute abscess of the neck Chest, abdomen, and gastrointestinal tract 9 Chest 89 Tracheostomy Underwater-seal chest drainage Simple rib fracture Flail chest Pneumothorax Haemothorax Acute empyema Surgical emphysema and mediastinal injuries Incision and drainage of breast abscess 10 Abdomen (general) 100 Laparotomy Repair of burst abdomen Abdominal injuries 11 Stomach and duodenum 113 Feeding gastrostomy Perforated peptic ulcer 12 Gallbladder and spleen 119 Cholecystostomy Ruptured spleen 13 Small intestine 125 Resection and end-to-end anastomosis Repair of typhoid perforation of the ileum 6 Contents 14 15 16 17 Appendix Acute appendicitis Appendicular abscess Appendicular mass Colon Colostomy Sigmoid volvulus Anus and rectum Rectal examination Proctoscopy Sigmoidoscopy Haemorrhoids Anal fissure Incision and drainage of perianal and ischiorectal abscesses Rectal prolapse Hemiae Inguinal hernia Femoral hernia Strangulated groin hernia Umbilical and paraumbilical hernia Epigastric hernia Incisional hernia Urogenital system1 18 19 20 Urinary bladder Drainage Management of ruptured bladder Male urethra Urethral dilatation Rupture of the urethra Male genital organs Scrotal hydrocele Circumcision Vasectomy Exploration of scrotal contents Paediatric surgery 21 General principles for paediatric swgery Special considerations Cut-down to umbilical vein 130 135 141 151 167 177 181 193 1For detailed descriptions of obstetric and gynaecological procedures, see Surgery at the dirtn'ct horpital: obstetrics, gy11tJecol()gy1 orlhopaedits, a'1d traumatology (Geneva, World Health Organization, in preparation). 7 Contents 22 23 Abdominal wall and gastrointestinal tract Operative reduction of intussusception Rectal prolapse Relief of strangulated inguinal hernia Urethra and genital organs Meatal dilatation Exploration of scrotal contents Treatment of paraphimosis Annex 1 Surgical trays Annex 2 Essential surgical instruments, equipment, and materials for the district hospital Index 8 196 201 205 217 227 Preface This handbook is one of three 1 to be published by the World Health Organization for the guidance of doctors providing surgical and anaesthetic services in small district hospitals (hospitals of first referral) with limited access to specialist services. The advice offered has been deliberately restricted to procedures that may need to be carried out by a young doctor with limited experience in anaesthesia, surgery, or obstetrics, using the facilities that can reasonably be expected in such hospitals. Wherever possible, the drugs, equipment, and radiodiagnostic and laboratory procedures described conform with WHO and UNICEF recommendations. Although the handbooks contain detailed descriptions and illustrations, the advice they offer is no substitute for practical experience. The reader is expected to have been exposed to all the relevant techniques during undergraduate or early postgraduate education. When necessary the text indicates which patients should be referred for specialized care at a higher level, as it is important to developing health services that young doctors and their superiors understand the limitations of practice at the district hospital. It has, of course, been necessary to be selective in deciding what to include in the handbooks, but it is hoped that any important omissions will be revealed during field testing. WHO would also be pleased to receive comments and suggestions regarding the handbooks and experience with their use. Such comments would be of considerable value in the preparation of any future editions of the books. Finally, it is hoped that the handbooks will fulfil their purpose - to help doctors working at the front line of surgery throughout the world. The three handbooks have been prepared in collaboration with the following organizations: Christian Medical Commission International College of Surgeons International Council of Nurses International Federation of Gynaecology and Obstetrics International Federation of Surgical Colleges International Society of Burn Injuries International Society of Orthopaedic Surgery and Traumatology League of Red Cross and Red Crescent Societies World Federation of Societies of Anaesthesiologists World Orthopaedic Concern. 1Also available: .A.nautbesia at the district hospitill; and in preparation: Surgery at the dislrict hospital; obstetrks, gynaecology, orthopaedics, and trautnato/ogy. 9 Preface and contributors Acknowledgements This handbook has been prepared as part of a collaborative activity between WHO and the International Federation of Surgical Colleges, which reviewed and endorsed the draft manuscript and illustrations. The editors acknowledge the valuable suggestions received from Dr G. Isaksson, Lund, Sweden, and Mnene Hospital, Mberengwa, Zimbabwe, and from Mr R.F. Rintoul, Nevill Hall Hospital, Abergavenny, Wales. Acknowledgements are also due to Churchill Livingstone, Edinburgh, the publishers of Farquharson's textbook of operative surgery (6th edition, 1978), for permission to adapt the drawings for Figures 13. lD, 16.1A, 18.3C,F, and 18.SA,B. Contributors Professor E.A. Badoe, Professor of Surgery, University of Ghana Medical School, Accra, Ghana Professor R. Carpenter, Professor and Head, Department of Surgery, University of the West Indies, Kingston, Jamaica Mr J. Cook, Consultant Surgeon, Department of Surgery, Eastern General Hospital, Edinburgh, Scotland Ms J.S. Garner, Chief, Prevention Activity, Hospital Infections Program, Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA, USA Dr M. Ijaz-ul-Hassan, Medical Superintendent and Chest Surgeon, Mayo Hospital, Lahore, Pakistan Dr A.E.O. Wasunna, Medical Officer, Clinical Technology, World Health Organization, Geneva, Switzerland, and Professor of Surgery, University of Nairobi, Nairobi, Kenya 10 Introductory note This handbook describes a limited number of surgical procedures. They have been chosen as appropriate for the doctor who does not have a formal surgical training, but who nevertheless has experi- ience, gained under supervision, of all the relevant techniques. With the exception of vasectomy, which may be an important part of national family planning programmes, the procedures included are considered essential for saving life, alleviating pain, preventing the development of serious complications, or stabilizing a patient's condition pending referral. Operations that require specialist skills or that could add unnecessarily to the doctor's workload have been avoided, and simple but standard surgical techniques have been selected whenever possible. Nevertheless, certain procedures that may appear technically difficult (for example resection and anas- tomosis of the small intestine) are included because they may offer the best chance of saving a patient's life. 11 FUNDAMENTALS OF GENERAL SURGERY Fundamentals For details of radiodiagnostic and laboratory techniques and drugs appropriate for the district hospital, the reader is referred to the following WHO publica- tions: 14 Manual of basic techniques for a health laboratory. 1980. PALMER, P.E.S. ET AL. Manual of radiographic interpretation for general practitioners ( WHO Basic Radiological ..[y.rtem ). 1985. WHO Technical Report Series, No. 689, 1983 (A rational approach to radio- diagnostic inwstigations: report of a WHO Scientific Group on the Indications for and Limitations of Major X-Ray Diagnostic Investigations). WHO Technical Report Series, No. 770, 1988 (The use of essential drugs: third report of the WHO Expert Committee). 1 Basic principles and techniques Surgical operations must satisfy three basic conditions: the wound must be inflicted without pain; haemorrhage must be arrested; and the wound must heal. It is especially the ability to ensure wound healing, by means of aseptic treatment, that has given impetus to modern surgery. Indeed, the necessity for asepsis regulates the conduct of surgeons, the "ritual" of operation, the form of instru- ments, and even hospital design and construction to such an extent that it is often taken for granted. Yet an understanding of the practical details of this system is imperative for any surgeon. Asepsis The most important cause of impaired wound healing is infection. Microorgan- isms reach the tissues during an operation or during changes of dressings or any other minor interference with the surgical wound. They are carried and trans- mitted by people (including the patient and anyone else who touches the wound or sheds organisms into the surrounding air), inanimate objects (including instruments, sutures, linen, swabs, solutions, mattresses, and blankets), and the air around a wound (which can be contaminated by dust and droplets of moisture from anyone assisting at the operation or caring for the wound). The aseptic treatment of a wound is an attempt to prevent contamination by bacteria from all these sources, during the operation and throughout the first week or so of healing. Modem methods of preventing infection in "clean" wounds also include the use of surgical techniques designed to make the wound less receptive to bacterial growth: gentle handling, sharp dissection, good haemostasis, and accurate apposition of the wound edges without tension when the wound is being closed. Bacteria can never be absolutely eliminated from the operating field, but practicable aseptic measures can reduce the risk of contamination to an acceptable level. Asepsis is influenced by innumerable details of operating technique and behav- iour. The probability of wound infection increases in proportion to the number of breaches of aseptic technique. There is no great difficulty in applying this technique to a single operation, but in practice the surgical team will be gathered for several operations - an operating list. Between operations the theatre floor is cleaned, instruments are resterilized, and fresh linen is provided. Potential breaches of aseptic technique can be minimized by proper ordering of patients on the list so that "clean" operations are done first. The longer the list the greater the chances of error; the risk of wound infection therefore increases as the list proceeds. For this reason, the surgeon should carefully consider the length and order of the list. A list system should not be considered at all without a certain minimum of equipment and a well-trained theatre staff. 15 I / :.i ''I \1 111 1 .. \\\ W,. The patient Skin preparation Fundamentals A ( Fig. 1.1. Preparation of the skin with antiseptic solution. Working from the centre of the operating field (A) to the periphery (B). Certain types of surgery, which are beyond the scope of the practice described here, require an exceptionally strict aseptic routine. But for the most part, safe surgery depends on well-tried and well-understood systems of asepsis, which are practicable in the district hospital. Asepsis depends on personal discipline and careful attention to detail, rather than on antibiotics and complicated equip- ment. There is no doubt that the level of discipline in operating theatres has declined since the dangers of wound infections have been mitigated by anti- biotics. Antibiotics, however, play little part in actually preventing wound con- tamination. This remains to be achieved by attention to people, inanimate objects, and air. Preparation for surgery The patient's stay in hospital before an operation should be as short as possible. Therefore, any tests and treatment that could prolong the preoperative stay beyond 24 hours should be carried out as outpatient services, if possible. Before the operation, correct gross malnutrition, treat serious bacterial infection, inves- tigate and correct gross anaemia, and control diabetes. As a routine, measure the patient's haemoglobin level and test the urine for sugar and protein. The patient should bathe the night before an elective operation. Hair in the operative site should not be removed unless it will interfere with the surgical procedure. If it must be removed, clipping is preferable to shaving (which can damage the skin) and should be done as close as possible to the time of opera- tion. 16 Duties towards the patient The surgical team Basic principles and techniques Fig. 1.2. Draping the patient. The operating field is isolated (A, B) and the drapes are secured with towel clips (C) at each comer. Just before the operation, wash the area around and including the operative site, and prepare the skin with antiseptic solution, starting in the centre and moving out to the periphery (Fig. 1.1 ). This area should be large enough to include the entire incision and an adjacent working area, so that you can manoeuvre during the operation without touching unprepared skin. Ethanol 70% (by volume) is recommended as an antiseptic, except for delicate skin, such as that of the genitalia and near the eye, and for children; 1% cetrimide (10 g!litre) is an alternative, as is 2.5% iodine in ethanol (25 g!litre). For major operations involving an incision and requiring the use of the operating room, cover the patient with sterile drapes, leaving no part uncovered except the operative field and those areas necessary for the maintenance of anaesthesia (Fig. 1.2). It is your duty to discuss with the patient the need for surgery and to explain in simple terms the nature of the proposed operation. Ensure that the patient understands, particularly if the operation involves amputation of a limb, removal of an eye, or construction of a colostomy, or will render the patient sterile, for example hysterectomy for a ruptured uterus. You must obtain the patient's ( or, if necessary, a close relative's) informed consent for the operation. It is your responsibility to ensure that the side to be operated on is clearly marked; recheck this just before the patient is anaesthetized. Also check that all relevant pre- operative care, including premedication, has been given. The patient's notes, laboratory reports, and radiographs must accompany him or her to the operating room. Anyone entering the operating room, for whatever reason, should first put on clean clothes, an impermeable mask to cover the mouth and nose, a cap or hood to cover all the hair on the head and face, and a clean pair of shoes or clean shoe-covers. 17 i \ \ Scrubbing up Fundamentals \\~ Fig. 1.3. Scrubbing up. Washing with soap and running water (A); further application of soap (B) before scrubbing the fingernails (C); washing the forearms with soap and running water (D); position of hands and forearms at the end of scrubbing to allow water to drip off the elbows (E); turning off the tap with the elbow (F). Before each operation, all members of the surgical team - that is those who will touch the sterile surgical field, sterile instruments, or the wound - should cleanse their hands and arms to the elbows, using soap, a brush (on the nails and finger tips), and running water (Fig. 1.3). The team should scrub up for at least 5 min before the first procedure of the day, but between consecutive clean opera- tions a minimum of at least 3 min is acceptable. 18