Learning Activities

ACTIVITY: List out how you would prevent needle stick injuries t your minor surgery room?
(8)

The last decade has highlighted the increasing numbers of newer type organisms like the ND
superbug etc that has added to the already existent problems caused by methicillin resistant
staphylococcus aureus, and the often forgotten hepatitis B,C and HIV infections. The common
organisms like staphylococcus and streptococcus causing cellulitis and abscesses on the skin
surfaces, anaerobic and mixed organisms in the perineal and axillary areas and onychomycosis
by fungi may require culture and sensitivity to target the organisms with the appropriate
antibiotics.
The operating GP should always be aware that he can be infected by these organisms through
infected blood, body fluids, an open wound, a puncture wound or needle stick injuries. The GP
,to start with should be vaccinated where possible and test himself for carrier status following an
accident at the operating room .The accident should be recorded, reported after the immediate
urgent step of allowing the area to bleed freely for a while and then washing the injured area
with soap and water.

Adoption of minimum infection control standards, monitoring the standards ,encouraging self
assessment of infection control and auditing standards of infection control will reduce exposure
to the biohazards associated with minor surgery. Comprehension of safety and sterility in the
operating room by understanding the OSHA requirements (OSHA regulations on Bloodborne
Pathogens),use of personal protective equipment, identifying risks associated with some
procedures,ways to dispose biohazadous waste are all knowledge to be acquired when we want
to do minor surgery.(7)

ACTIVITY: What do you understand by the terms disinfection, sterilization and autoclaving

Ref:
1. Zaimastura Binti Ibrahim. Management and Disposal of Clinical Waste (Case Study:
UKM)

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 2. Alene Burke & Associates ; safety in the operating room and other areas where invasive
procedures are done. CME ; Florida Board of Nursing.
3. Jim Ramsay, PHD MA; Needle sticks and Safer Needle Technology in
Healthcare.American Society of safety Engineers; 2003 Oct 8.
4. Susan Q. Wilburn, MPH; Needle sticks and Sharps Injury Prevention; Online Journal of
Issues in Nursing ; Sept 30, 2004.
5. http://www.osha-slc.gov/needlesticks/needlesticks-regtxtrer.http

C. INSTRUMENTS:

a. Resuscitation Set:
Whether the General practice has minor surgery facilities or not, the necessity of preparedness
for resuscitation has to be stressed. A patient may collapse due to a simple vasovagal attack,
epileptic attack or he may have had a myocardial infarction, cerebrovascular accident, pulmonary
embolism or even anaphylactic reaction.

Is a requirement under the HCSFA and consists of –

- syringes and needles,
- drugs - adrenaline, morphine, atropine, diazepam, hydrocortisone,lignocaine
- plasma expanders ,intravenous sets, intravenous cannulae and infusion sets
- bandages and plasters
- simple disposable airways, umbo bags, electrosuction equipment, oxygen
- ECG machines and cardiac defibrillators.
- endotracheal tubes, airways, suction apparatus

b. Surgical Instruments :
Required for surgery at the GP clinic and will include paraphernalia that will be commonly
used in actual surgery depending on the special interest of the GP and will include ENT
equipment, gynaecological instruments, the orthopaedic instruments and the range can be as
wide as is required.
Good quality instruments that can be maintained without rusting or blunting are a worthwhile
investment. Stainless steel is the best material for surgical equipment.

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When starting aa operation room, it may be wise to start with a scalpel handle and blade, a
needle holder, a tooth and a plain forceps, artery forceps, sterile sutures and then building up to
equip the areas of interest.
Displayed Lists of instruments for the common surgeries will be efficient. ex abscess.
lacerations etc

c. The Steriliser:
This equipment is a must and can be used from a central location in group practices or a small
sterilizer in small practice .The principle is that steam under pressure with temperatures reaching
136 degrees is used. Ideally instruments must be brushed clean after use, drip dried, packed in
sterile surgical paper and sterilized dressings, drapes, towels and gowns.
Some equipment having fibre optic equipment when used has to be soaked in glutaraldehyde.
A hot water disinfector (HCSFA) or dry heat or even ultraviolet sterilization can be used. Waste
material must be thrown into the Clinical Waste Disposal Bin and the sharps into the sharps
container for incineration .

d. The Electrocautery :
A very useful tool where the red hot platinum tip can be used to cut or coagulate using electricity
or rechargeable cadmium batteries. The various platinum ends i.e the ball tip is used for
coagulation, the cutting for dissection purposes, the small puncture electriode and the cold point
tip for subungual haematoma, spider naevi and small papillomata .The sterilization of the
platinum end is simply by heating the tip to red heat..

III. EMERGENCIES :

a. Haemorrhage – overt, occult

b. Shock- tachycardia, thready pulse, sweating, narrow pulse pressure, breathlessness,

confusion
c. Unconsciousness – head injury, hypoglycaemia, ketoacidosis, CVA,
hypoxia,hypotension,hypertension, eclampsia, drug intoxication

* Display lists of common causes of collapse you would look for including myocardial
infarction, epileptic fit, drug overdose, haemorrhage, vasovagal faint, anaphylactic reaction.
.
* Display Table of GSC: Mutagh

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Table 16.1 Glasgow coma scale

Score

Eye opening (E)

 Spontaneous opening 4
 To verbal command 3
 To pain 2
 No response 1

Motor Response (M)

 Obey verbal command 6
 Response to painful stimuli
 Localises pain 5
 Withdraws from pain stimuli 4
 Abnormal flexion 3.
 Extensor response 2
 No response 1

Verbal responds (V)

 Orientated and converses 5
 Disorientated and converses 4
 Inappropriate words 3
 Incomprehensible sounds 2
 No response 1

Coma Score E + M+ V
Minimum 3
Maximum 15
* Display standard protocol when you assess unconscious patient
# shout for assistance first !!
A. Airway maintainence
B. Breathing
C. Circulation and IV line
D. Drugs: administration of medications
E. ECG

Ref: WHO manual Surgical Care at the District Hospital (SCDH) part of WHO Integrated
Management on Emergency and Essential Surgical Care (MEESC) tool kit.

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IV. Minor Surgery –The Approach
It is important to approach a problem systematically with a definite order so as not to miss out an
important point. Have a stethoscope, a measuring tape, a skin pencil, a torch, a pin, a wisp of
cotton, a percussing hammer

Case taking;
1. Always GREET, INTRODUCE YOUSELF,CREATE A RAPPORT
2. THEN register with name age, religion, sex, occupation, address
3. THE HISTORY
- Presenting complaints; what ?,how long ?,how it started (onset)?, progress and
treatment received
- Past history –has he had a similar problem before …or a related problem?
- Family history – diabetes, tuberculosis, haemophilia
- A questionnaire gathering information on – medications
-current medical problems ex:CAD
- past hospitalisations
- if on a pacemaker
-diabetes,immunocompromised state
- allergies
- ? prone to keloids

4. PHYSICAL EXAMINATION
a) General appearance-build, status of musculature, anaemia, emanciation
- facies
- attitude-ex an externally rotated limb in a case of # neck femur
- decubitis-position in the bed

b) Vital Signs-pulse, blood pressure, respiratory rate etc

c) It is important to examine all parts of the body (for diagnosis / differential diagnosis)

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Ex:-
- Argyll Robertson pupil relates to retention of urine or Charcot’s joints
establishing tabes dorsalis as a cause
- An unexplained abdominal pain in a patient with spinal caries may be because of
tuberculosis

5. LOCAL EXAMINATION

“eyes first and much, hands next and little and tongue not at all”
Sir George Humphry

- Inspection- Always expose the whole area AND compare to the corresponding side
“ the eyes do not see what the mind does not know”
- Palpation- train your fingers to discriminate pulsations texture, hardness, fluctuancy
- Percussion- the sounds define solidity, distension
- Auscultation crepitus, friction rubs,

ALWAYS examine the draining lymph nodes !

6. DIAGNOSIS:
From your differential diagnosis, you should be able to point out the single diagnosis. To make
the diagnosis you must be able to decide if this is a case that can be treated at the GP’s Office,
whether it should be done straightaway of if it can be scheduled, whether the patient has to be
referred to a specialist.

To make your diagnosis complete, it may be necessary if the patient is fit to withstand surgery
ex a patient in a poor physical condition may only do the surgery if it is absolutely necessary
or he may have to be built up. A patient with poor abdominal musculature may have to
prepare for a hernioplasty instead of a hernioraphy. The general practitioner who is his family
physician is well suited to counsel the patient on the best course of management.

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7. TREATMENT:
Before the surgery is performed, a consent must be obtained from the patient. A detailed
explanation must be offered to the patient on the nature of the operation. A decision must be
made on the anaesthetic to be used The surgery /procedure must be written out in detail.

COMMON SURGICAL PROCEDURES AT THE GP OFFICE:

A.TRAUMA

I. Lacerations:
Written record of treatment of lacerations dates back 2500 BC. Various animal, vegetable and
mineral substances were used as balms and jaws of ants was used to approximate wound
margins.
The gold of treatment is to avaid infection and to achieve an aesthetically pleasing scar.
The first and most common surgical skill is the art of suturing! A GP‘s bread and butter from the
surgical aspect is the laceration usually caused by a fall , an accident while working or from a
Road Traffic Accident. (11). A ready pre-packed and sterilized “trauma set” is very useful at
the GP’s Office and it should have a minimum of :
1. a needle holder
2. scalpel handle
3. surgical blade .
4. dissecting forceps
5. stitch scissors.
A chromic catgut with needle size 3 and a monofilament nylon suture size 3 and size 4 along
with syringes and needles with local anaeathesiae must be on standbyalong with the standard
tetanus toxoid injection and a resuscitative set which must be available and ready for use.
The patient and the doctor must be comfortable and good illumination before the first step of
thorough inspection of the wound is done.
Knowing the nature of injury and the time the injury took place will help us decide on the course
of the management .We ought to assess the organ or tissue injured, the extent of injury and if
there is contamination. Then a through cleansing is required. After debridement and
haemostasis,we decide whether the repair is going to have a primary repair done or if we are

7
going to do a delayed primary suture (in about 2 days) or allow secondary healing and do a
secondary suture or even a graft if necessary at a later date.

Caution:
Obtain a history of nature of injury, determine the location of injury to help decide on the
management plan for presence of nerve, tendon or artery injury. Rule out fractures by testing for
tenderness and assess if there is loss of function. Testing for distal function, sensation and testing
for tenderness along the long axis helps to locate the area of nerve or tendon injury and the
presence of fracture. Stab injuries, high pressure guns and puncture wounds deserve special
attention.(11)
We can have a concussion from a heavy fall on the coccyx. After a fall, look for fractures around
the wrists in the elderly, around the ankle and foot in youngsters and for fractures around the
elbow in children

II. Foreign Bodies:

It is a common cause of a malpractice action besides causing delayed healing .Care must be
taken to look for and remove debris, splinters, glass slivers after a RTA, oilpalm thorn prick
occupational accidents and needles in the feet of children. Ticks, fishhooks, gunshot wounds,
inoculation wounds have unique methods of removal and the GP is advised to refer to the
reference material for details.

III. Skin closure:

Good approximation with minimal tension with approximated edges slightly averted is desired
for rapid healing, usually about ten days. Depending on the size and site of the laceration
approximation can be done with a self-adhesive tape, a steristrip, using hair in strands to knot
over a laceration in the scalp, using tissue adhesive like histocryl and of course suturing.
It is good to understand the type and size of sutures that is to be used. The commonly used sizes
are 2 for soles, palmar surfaces and scalp whereas the rest of the body get good scars with size 4
and smaller size for face.
The commonly used suture materials are absorbable plain catgut for approximating the deeper
layers like muscle and dermis, chromic catgut when we want the suture to withstand absorption
till the wound heals like in after a circumscision, braided silk for scalp wounds. Monofilament

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sutures are now commonly used and the polyglucolic acid (dexon) and vicryl sutures have the
advantage of being absorbable.
The suturing itself may be done using interrupted sutures with reef knots for wounds that are
wet, in moist areas, wide lacerations, scalp areas, palms and soles and in areas where a
haematoma is like to collect. A subcuticular stitch is useful in areas where the edges can be
approximated and minimal scarring is preferred. A continuous stitch is seldom used. A mattress
suture are used where tissue a are lax or in the deeper lacerations to attin approximation and
prevent empty spaces for haematoma collaction.
Dressing should be able to prevent contamination, absorb any secretions, provide a splinting
action and reduce movement of injured part. A discharging wound may require a melolin
dressing or a vaseline gauze and if infected a tulle gras(has antibiotics).A spray form like acrylic
resin can be used on areas where conventional dressings are difficult to apply like the scalp. The
elastic bandages aid compression in moving areas. The stockinettes dressings are useful in areas
like the perineum, axilla, scalp and the tirbigrip over the limbs and fingers.

Ref: Judd E Hollander,Adam J Singer : Laceration management.Annal of Emergency

Medicine.34.3;Sept 1999.

IV.Haematomas:
All surgeries must be done with precautions to prevent haematoma that can occur in an dead
spaces. All haematomas must be drained to prevent it from getting infected, forming abscesses or
becoming organised and causing disfigurement like the cauliflower ear. The haematoma must be
drained and compression applied.

Dressings:
- the type of dressings used in the operating theatre will depend on the
purpose it is used for. The face and scalp may not require any dressings.
Dressings may be used to provide additional support during the healing
phase, protect from contamination or even help to absorb secretions.
- Nowadays there are many types of dressing material. The dressing may
be of a non adherent type for burns, an antibacterial dressing, replace the
traditional gauze when used as a spray form, a net stockinnette type used
over limbs, elastic roller type etc

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B.SWELLINGS

It is important to note the site of the swelling and the characteristics of the swelling.
The 5S-site,size,shape , surface ,skin over the swelling along with the transillumination test and
and fluctuancy will help us arrive at the diagnosis in most instances.

I. Pre-Operative Anaesthesiae:
a. Many techniques are available to anaethetise an area in preparation for a minor surgery-
Ethyl chloride spray is not not quite effective as a surface anaesthesia but prepartions such s
lignocaine 4% as eye drop lotion or amethocaineHCL 0.5 % can be used effectively for the
cornea and conjunctiva or even the nose, pharynx, larynx and urethra. -Topical creams like
the Emla or gesicain can be applied for 45minutes to 2 hours on skin before a procedure like
a fulguration of a seboborrhoic keratoses
- Infiltration Anaesthesia is widely used for minor surgery in the GP Practice. Lignocaine is
the most commonly used compared to prilocaine and bupivacaine, has more effect on the
sensory than the motor fibres and has no effect on the blood vessels. The maximum dose of
lidocaine is 200 mgm for a 70 kg adult which is 20mls of 1% lignocaine.Toxic effects is
caused by depression of the medulla and stimulation of the cerebral cortex with resultant
complaints of blurred vision, nausea, tremors and convulsions and respiratory arrest.

Nerve Blocks:
Is done by infiltration around a nerve and may be done by:
1) Intravenous nerve block(Bier’s Block) :
helps to provide a bloodless field besides the anaesthesia and is particularly useful in removing
foreign bodies, ganglion etc on the upper limb. About 2,5 mgm/kg of 0.5% lignocaine (usually
adult is 30 mls) is given into an indwelling needle on a limb that is isolated from circulation with
an inflated BPR cuff or rubber strapping. Patients with liver ds, cardiac problems, fits or
lignocaine allergy should be excluded. A resuscitative set should be on standby at all times. That
maximum time of inflation should not be more than 45 minutes. The tourniquet should be
released slowly.

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2) Regional nerve blocks:
the most commonly used minimally invasive method of obtaining anaesthesia for a minor
surgical procedure at the GP Office. It is done by injecting about 2-3 mls of 2% lignocaine or 5
mls of 1% lignocaine ( always aspirating to check for blood) and waiting for 5-10 minutes for its
effect ex:
Penile Nerve Block:
5mls of 0.5% lignocaine circumferentially at the base of the penis with a larger portion being
infiltrated into the dorsal surface and in the ventral paraurethral spaces.
3)Facial nerve Blocks:
-Supraorbital nerve Block done by injecting 2.5 cms lateral to midline at the upper border of the
orbitover the supraorbital foramen.is useful for surgeries on the forehead and scalp.
-Infraorbital Nerve Block: by alighning the needle along the long axis of the second premolar
and entering at the gingivomucosal fold and inject the anaesthetic just short of the infraorbital
foramen.
-Mental nerve Block can be done for excisions or suturing of lacerations in the lower lip and
chin.It is done by injecting the lignocaine at a midway point from gum margin and lower border
of mandible .The needle is directed in alignment with the second lower premolar and penetrating
at the gingivomucosal fold.
4)Posterior Tibial Nerve Block:
Particularly used to avoid the pain of local infiltration in a cornified area like the sole. The
injection is done in an area midway between the medial malleolus and the Arclilles tendon,
aiming towards the underneath of the bone and injecting 2-5 mls of the LA. This method is
useful for suturing lacerations and other intradermal lesions like verrucae.
5)The Median Nerve Block:
Is done for anaeasthesiae of the palmar surface of the radial 3.5 digits by injecting just lateral
to the palmaris longus tendon(medial to the flexor carpi radialis tendon).
6)The Radial Nerve Block:
Is done by injecting 3 mls in the anatomical snuffbox and 2mls subcutaneously over the lower
end of radius
7)The Ulner Nerve Block:
About 5 mls of 1% lignocaine is injected into an area just medial to the Flexor carpi ulnaris jus
before its insertion into the pisiform bone. To block the dorsal branch of the ulner nerve, a

11
furthw 2 mls is injected from the medial side of the ulnar styloid to the middle of the back of the
wrist.
8)Digital nerve Blocks:
We have to remember that adrenaline shpuld never be used to avoid ischaemiaor gangrene and
in conditions like raynaud’s ds where peripheral circulation is compromised. The best landmark
to give the anaesthetic is at the is the palmar or plantar borders with skin border and directing the
needle in a circumferential manner.
II.Technique of pre-operative preparation:
- paint with povidone-iodine in spirit
- draw local anaesthetic and inject at selected site slowly using a fine needle
- scrub –up and then drape the patient
- open pre-packed sterile surgical set and you are ready to proceed after you have confirmed
that you have consent.

Lipomas/ sebaceous cysts: (12a)

The most common swellings that is commonly operated upon in the Minor operating theatre of
the General Practitioners’ Office are sebaceous cyst and the Lipoma. The trichlemmal cyst (pilar
cyst derived from hair follicle) and epidermal cyst(from epidermal lining of the pilosebaceous
follicles) are referred to commonly as the sebaceous cyst.

Sebaceous Cyst:
Depending on the size, a small incision with pressure on both sides will get the cyst out or a large
cyst will require an elliptical incision. The curved McIndoe will then be used to clear the
adhesions and tease the cyst out. The skin is then closed with interrupted
In the case of the lipoma, the size and shape is determined before the surgery. The skin is then
incised after the aseptic procedures and the infiltration of anaesthesiae. The lipoma usually
bulges out especially if pressure is applied on the sides. Skin is then closed after ensuring an
elipse is removed for the larger swellings and precautions taken to prevent leaving an empty
space.
Ref:
http://www.wrongdiagnosis.com/l/lipoma/treatments.htm
########diagram page 46:3.3a

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Abscesses
An area of pain with throbbing with fever and chills is suggestive of cellulitis or lymphangitis. It
could be treated with antibiotics and suppuration is induced. If it does not resolve with the
antibiotics and an abscess forms, than an incision and drainage should be done. The type of
anaesthesiae will depend on the size and location of the abscess – it may be an ethyl chloride
spray, surface infiltration with a local anaesthetic by injection or even an inhalation anaesthesiae
in case of a child.
The abscess is drained after an incision, the pus sent for culture and sensitivity and a drain or
pack inserted .then daily packing inserted till wound heals.

Ref:
http://www.stephaniemarohn.com/firstaidabscess

Incision and drainage

Instruments required:
Povidone-iodine in spirit
- syringe with 25swgx 5/8 needle
- lignocaine
- scalpel handle size3 and scalpel blade size15
- stitch scissors and McIndoe curved scissors
- tooth dissecting forceps
- mosquito forceps
- Needle Holder
- surgical scissors
- braided silk or nylon size 3 on curved cutting needle

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C.SKIN LESIONS:

The GP can do most skin lesions at his practice. He should refer the malignant melanoma and
other large benign lesions that may require skin mobilization for closure to the specialist.
Surgeries in the face, posterior triangle of neck, axilla, femoral triangle or even the breast should
be done with a lot of caution at the GP setting. Aged patients and young children should be
carefully assessed before surgery is scheduled.

SURGICAL PROCEDURES OF THE SKIN:

Incisions:
A surgeon is recognized by the scar he leaves behind. Almost invisible scars can be produced
following Langer’s lines (follows crease lines or runs perpendicular to underlying muscles or
transversely across joints. The incision is always perpendicular to skin surface.

Excisions:
The first decision to be made is whether we have to operate. An infant’s strawberry naevus,
warts and molluscim may regress on their own. Then we have to decide the line of the scar.
Incisions that follow the skin crease are neater. Finally we have to decide on the method of
surgery, whether it will be excised, curetted , cauterized, dessicated, fulgarised or treated with
diathermy or by radio surgery..

Electrocautery:
The cutting electrode is used for dividing skin tags, intradermal naevi, papillomata. The ball
ended coagulating electrode is useful for sealing small bleeding points, the cold point burns
which is used for spider naevi.

The unipolar diathermy generates very high voltage but with low current. In dessication the
electrode is inserted into the tissue whereupon the heat will destroy the tissue. In fulguration the
electrode is held above the surface being treated whereupon a stream of sparks from the
electrode will char and destroy the tissue.

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Radio surgery is a procedure by which tissue is removed or destroyed by electrical energy with
less trauma, less discomfort and less scarring. The pure filtered waveform is used for
cutting(incisions),the fully rectified waveform is used when bleeding is expected as in skin tags ,
keloids, keratoses and a partially rectified waveform for coagulation as in telangiectasia and
spider veins. A fulgurating current is used for haemostasis or even small cysts.
Radio surgery is very commonly used in removing pigmented nevus, intradermal nevus,
melanocytic naevus, actinic keratoses, seborrhoeic warts, telangiectasiae, epilation rhinophyma,
xanthelesmata etc.

Cryotherapy:

Used for warts, seborrhoeic warts, solar keratoses, verrucae .molluscum contagiosum,
dermatofibroma etc .It uses either carbon dioxide, nitrous oxide or nitrogen.
Liquid nitrogen destroys tissues by freezing it to -196degrees C.

Chemical Cauterisation:

Only superficial lesions can be treaed. It is cheap but controlling the area to be treated may be
difficult. Silver Nitrate, Liquefied phenol and monochloroacetic acid are commonly used
Silver nitrate is used as a chemical cautery in lesions like hypergranulation, epistaxis, cervical
erosions, small pyogenic granulomas.chronic fistulae, ingrown toe nails.

Excisions: Skin tags, intradermal naevi- are snipped off and the base curetted
Warts, pyogenic granuloma, solar keratosis, seborrhoeic warts, keratoacanthoma , molluscum,
cutaneous horn are managed by currretage, radio surgery or cautery. Sebaceous Cyst,
dermatofibroma is managed better by excision

Skin Closure

Is usually by suturing-interrupted (mattress or plain) and sometimes subcuticular continuous.

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D.MINOR SURGICAL PROCEDURES

TOE NAIL SURGERY

Methods (15)
- podiatriation
- gutter treatment
- Nail avulsion
- Wedge resection

One of the most common problems encountered in the general practice is the ingrown toe-nail, It
may be caused by a structural anomaly where the nail has increased convexity and the edges
grow into the sides, dirt accumulates and infection occurs or it may be an increased nail
convexity where the excessive incurving pushes the nail edges into the tissue at the sides. Ill
fitting shoes, incorrect cutting of toe nails and poor hygiene has also been attributed as causes.
Conservative treatment is attempted at first with local cleansing and trimming of edges of the toe
nails or inserting a ‘spatula” at the toe edges and applying antibiotics and adsorbants like
magnesium sulphate.
Surgical treatment may be by phenolisation: following the surgical removal of narrow strip of the
side of the nail, phenol is applied over the germinal epithelium. Phenol in 80% in water prevents
the nail at the sides from regrowing , destroys the nerve endings and is also an antiseptic.
In the ‘wedge resection’ method, a wedge with the nail edge and the tissue (with a vertical and
then a lateral incision) extending posteriorly to the germinal epithelium is removed under digital
nerve block.

Nail bed ablation with phenolisation is a procedure after removal of the toe nail. This procedure
is used for recurring ingrowing toenails or in cases of the grossly distorted onychogryphotic toe
nails.

The most common injury, the subungual haematoma is drained by applying a red hot needle
.paper clip or using electric cautery over the nail, thus drilling holes that allow drainage.

The commonly seen mixed pseudo cyst which occurs at distal interphalangeal joint or the distal
joint is treated by intralesional steroids after aspiration of the thick mucous content.

16
Ref: British medical Journal W A Wallace,D D Milne, T Andrew .Gutter treatment for
st
Ingrowing Toenails.BMJ.21 Aug1999.
######### Diagram:Toe nail Surgery

ANORECTAL SURGERY

Incidence of one- rectal dieses increasing ** poor eating habits fast ** life. The basic principle of
the approach to anorectal surgery is that a per rectal examination, a proctoscopy and planning for
a sigmoidoscopy is done for all cases of haemorrhoids or rectal bleeding because carcinoma
rectum should be suspected until proven otherwise

Haemorrhoids :
First degree haemorrhoids are “visible but not palpable” and may be treated with injection,
photocoagulation nor cryotherapy.
Second degree haemorrhoids tend to protrude after defecation but may spontaneously reduce
after the act and is treated as above or sometimes ligation especially when the pile is fibrosed.
Third degree haemorrhoids need to be reduced manually after defacetion and may be paimful
due to inflammation, thrombosis and strangulation. A surgical referral for treatment by injecting
sclerosants, band ligations( only if above anorectal ring) ,
Anal fissure which are a common accompaniment of constipation are treated by dilatation or by
fissurectomy.
Perianal haematomas occur after straining to pass stool and is simply drained by deroofing and
evacuation of the blood clot followed by dressing and cold pack. If left untreated, it heals by
becoming a skin tag which can be excised.
Perianal abscesses are as all abscesses treated by an Incision and drainage but a cruciate insion
with trimming of the corners allows easy post surgical dressing.

Pilonoidal sinus is another area that has to be managed with care.it can be quite unassuming and
the GP must always be on the lookout for comprehensive management.

17
Treatment Options for Haemorrhoids:
 Rubber band Ligation
 **
 Cryotherapy
 Stapled Haemorrhoids
 Surgical Haemorroids
Costra** for office practice
- Anal sterosis
- Bleeding haemorrhoids
- Grade III or IV haemorrhoid
-Pt on NSAID or blood **

Ref:
1. http;//www.worldwidewounds.com/2003/decenber/miller/pilonoidal-
sinus:06072005
2. Robert A. Scarborough;Proctology for the General Practitioner:Official
Journal of the California Medical Association.

VARICOSE VEINS

The two sets of veins in the legs, the deep and the superficial are separated by fascia but
connected to each other by perforating veins. The perforating and superficial veins both have one
way valves and the blood is pumped upwards and into the deep venous system.
by the calf muscles
Veins below the knee are ideal for treatment and care must be taken to exclude from treatment
patients suffering from deep venothrombosis or those patients with systemic diseases like
diabetes and those on OCP.
A tourniquet may be applied progressively lower from upper thigh downwards to seek level of
valve incompetence.
Sclerotherapy and stab avulsions are the commonly used methods of treatment. The simplest
method is to do percutaneous ligations for isolated veins.
Complcations of varicose veins like superficial thrombophlebiitis is treated with crepe bandage
strapping, rupture by compression and bandaging and repair if necessary: venous ulcers by honey

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or sugar dressings covered by compression bandages or turbugrip with advise to elevate the
limbs as frequently as possible.

OPTHALMOLOGY:

Confidence armed with knowledge of anatomy of the eye, adequate instruments used in minor
surgery of the eye and the examination technique itself are the basic essentials of dealing with
opthalmological problems.

The eye kit comprises of snellen’s chart, multiple pin holes, fluorescein strips, cotton buds,local
anaesthetic, isotonic saline.a manifying glass and a torch.

The common simple procedures that area done at the GP Office include I&D of meibomian cyst,
lid surgery. The GP should know how to avert the upper eyelid for near complete visualization of
the tarsoconjuctival surface of the upper eyelid.

Fluorescein staining is very useful to identify corneal erosions, ulcers or foreign bodies and the
schirmer’s test can be used to gauge the dryness of the conjunctiva (15 mm of the paper is
moistened in five minutes when it is hung over the lower eyelid).

The meibomian cyst is a retention cyst precipitated by an infection. If conservative management

fails, an incision and curettage through the tarsoconjunctival surface after anaesthetizing with
lignocaine 1%and applying a meibomian clamp and averting the lid.

Removal of foreign body should be done under a magnifying glass and after anaethetising .with a
topical anaethetic. A superficial foreign body may be lifted off with a cotton bud, and an
embedded one lifted off with a disposable sterile needle. It is important to examine for rust in:
welder’s injury and if persistent stains remain, refer to the ophthalmologist.
Surgery of the eye lids should avoid the lid margins

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 Ref:
1. Hannah Gilchrist, Graham Lee.Management of Chalazia in General Practice
Australian Family Physician.vol 30,05052006
2. M.F Adamjee, MB.Ch, DA, DCH. Department of Ophthalmology, Nelson R. Mandela
School of Medicine, University of Kwazulu. Natal. Durban CME October 2007 Vol. 25 No.
10.

EPISTAXIS:
Most nose bleeds arise from the Little’s area that is located in the upper anterior aspect of the
nasal septum. The bleed s are usually self limiting. However, if persistent or severe, very heavy
nasal bleed or a posterior epistaxis is better referred for admission into hospital.

To treat chronic epistaxis silver nitrate may be used to cauterize the area of with advise not to
blow his nose for a few hours.
Alternatively, electrocauterisation with electrocautery, fulgarisation with diathermy or better
still precise coagulation by radio surgery may be done after anasthetising with lignocaine spray.

Ref:
Dennis Pashen,Maurice Stevens.Management of Epistaxis in General Practice
Australian Family Physician: vol 31 no:8:august 2002

CIRCUMSCISION

The foreskin is usually retractile by four years of age. Phimosis and paraphimosis are medical
indications for circimscsion. The surgery is done under general anaesthesia or using a ring block
at the base of the penis with 1% lignocaine. A dorsal and vebntral cut is made on the forskin up
to half a centimeter from the coronary sulcus after stretching it with artery forceps. Then a
circumferebtial division id done half cm fom the coronary sulcus and thn the cut end s of the
mucosal layer and skin are sutured after control of possible bleeding vessels.

######### diagram: of paraphimosis-incision(page 206,fig 16-c

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