Primary Surgery

[Volume One: Non-Trauma]

Chief Editor
Michael Cotton
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AT LEAST 20 SURGEONS IN ONE

The cover illustration attempts to show (with some artistic licence) the maldistribution of surgeons around the world, depicted with the famous Gall-Peters
projection which better demonstrates land mass than the more traditional Mercator projection.

So, here you are, one of our readers, faced with the difficult problem of knowing what you do to help a surgical patient in all these fields, and unable to refer him to
an expert. Reading from the top left in a clockwise direction you may need to be: a plastic surgeon, a neurosurgeon, a thoracic surgeon, a GI surgeon, an ENT
surgeon, a vascular surgeon, a paediatric surgeon, an obstetrician and gynaecologist, a urologist, a proctologist, an orthopaedic surgeon, a hand surgeon,
a maxillofacial surgeon, and an ophthalmic surgeon.

This drawing does not include your role as a trauma surgeon, a dental surgeon, a leprosy surgeon, an HIV specialist, an oncologist, an
anaesthetist, and an 'intensivist', in addition to doing everything else you have to do in medicine, paediatrics, psychiatry, and management!
We hope these manuals will help you in some of these varied and exacting tasks.

Remember though the famous wise words of the London surgeon, Sir Astley Cooper:
“A surgeon should have an eagle’s eye, a lady’s hands and a lion’s heart”.

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Primary Surgery
Volume One: Non-Trauma (Second edition)
Editors

MICHAEL H. COTTON, MA(Oxon), FRCS(Eng), FACS, FCS(ECSA), FMH(Switz).

Former Professor of Clinical Practice, National University of Science & Technology, Bulawayo, Zimbabwe,
Former Consultant Specialist Surgeon, Mater Dei & United Bulawayo Hospitals, Bulawayo, Zimbabwe,
Medecin Associé, Service des Urgences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.

OLIVE KOBUSINGYE, MBBS, MMed Surgery (Kampala), MPH.

Regional Advisor, Disability/Injury Prevention, WHO Brazzaville, Congo & Kampala, Uganda.

The late IMRE J.P. LOEFLER, MD, FRCS(Ed), FCS(ECSA).

Professor of Surgery (Retired), Nairobi, Kenya.

STEFAN POST, MD.

Professor of Surgery & Director, Department of Visceral Surgery, University Clinic, Mannheim, Germany,
Former President, Deutsche Gesellschaft für Tropenchirurgie. Universitätsklinikum, Jena, Germany.

DOUWE A.A.VERKUYL, FRCOG, PhD.

Consultant Obstetrician & Gynaecologist, Bethesda Hospital, Hoogeveen, The Netherlands,
Obstetric & Gynaecological Advisor, Royal Tropical Institute, Amsterdam, The Netherlands.

CHRISTOPHER BEM, FRCS(Eng), MD, MPH.

Consultant ENT and Neck Surgeon, Bradford Teaching Hospitals NHS Trust & Honorary Senior Lecturer, Leeds Medical School,
Visiting Lecturer, Malawi Medical School, Blantyre& Lilongwe, Malawi,
Former Senior Lecturer, General Surgery and Trauma, University Teaching Hospital, Lusaka, Zambia.

ANDREAS M. FETTE, MD, PGD, DDU, EMDM, FMAS, EBSQ, EBPS.

Professor of Paediatric Surgery, University of Pécs Medical School, Hungary& International Medical University, Vienna, Austria,
Head Pediatric Surgeon, National Research Centre for Maternal and Child Health Care, Astana, Kazakhstan.

Copy Editor.
MINA LAHLAL, MD, Mag.a (Intl. development)
Tropeninstitut & Department of Development Studies, University of Vienna, Austria,
Visiting Lecturer, CapaCare Surgical Training Programme, Masanga Hospital, Sierra Leone,
Former Emergency Medical Services Programme Team, WHO Barcelona, Spain.

Illustrations Editors.
THOMAS EGLSEDER, MD, Facharzt Allgemeinchirurgie, Klinikum Ludwigsburg, Germany.
BÄRBEL BINDING, MD, Former Facharzt Allgemeinchirurgie, Missionsärztliche Klinik Wurzburg, Germany.
ARTHUR E. COTTON, BSc Hons, BMBS, St Thomas’s Hospital, London, UK.
FELIX RIESE, Technische Hochschule Aachen, Germany.
JULIUS ECKE, Medizinische & Wissenschaftliche Illustration, Germany.
(with grateful acknowledgement to the huge work of previous illustrators whose work has given the book its unmistakeable look and feel)

Valuable contributions have been received with grateful thanks from:

Mirjam Apperloo, Girish Desai, Bernd Domres, Christina Freymann, Khurshid Ghani, Taurai Gunguwo, Walter J Jana, Hans-Joachim
Jessen, Lutz Künanz, Sarah Mills, Henning Mothes, Solwayo Ngwenya, Erlick Pereira, Norbert Perera, Thomas Raassen, Antje Volker
Rathke, Alexander Graf von Roon, Matt Sherratt, Glenn Strauss, Kees Waaldijk, Torsten Wilhelm, Arshad Zafar, & Sylvia Zayer

[email protected]

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FOREWORD
When Michael Cotton invited me to write the Foreword to this second and significantly changed edition of
Primary Surgery, I was delighted, and I have three reasons.

First, I greatly respected Michael’s work as a front line surgeon and a most dedicated teacher of surgery
during his many years in Bulawayo, Zimbabwe. I was often asked by colleagues in training where they
should go to learn operative surgery in Africa; Michael was always the one who came to mind first,
because I knew that he would take the trouble to teach sound, careful and relevant surgery. I knew also that
his colleagues would be working with a man of resolute integrity. This book is the expression of all his work
as a surgeon at the front line; it was a further delight when I found that he had recruited Olive Kobusingye to
be his assistant editor. I have been with Olive on take-in evening ward rounds at Mulago Hospital. Kampala;
I witnessed team work, clear thinking and the practice of excellent clinical surgery. Thus this book has
editors who have been proved as teachers and surgeons.

My second reason for delight is that the book will be a real help to those who have to practise surgery at the
front line. For too long such colleagues, whether surgical clinical officers or medical officers, have not had a
book which was written for them, to enable them to treat rural patients, the injured and those who are unable
to meet the costs of travel to, and accommodation at, a regional or national teaching hospital. I believe that if
the book’s sound common sense and clear practice are followed, the victims of injury will be treated early
and acute emergencies will be dealt with before they progress and complications develop. Patients will thus
be able to get back to work and families will not suffer socially and economically.

Finally, I am certain that, where good life-saving and worker-restoring surgery is done, people who may have
been afraid to bring their family member to hospital will lose that fear. Good surgery will be a great advocate
and foundation for the public health of a community, now assured that disease and injury which previously
could not be treated is not only treated but treated successfully. Surgery will no longer be forgotten by the
administrators and those who are responsible for providing a nation’s health service; it will take its rightful
place in health care. This book, properly used, will help to accomplish this and will be blessed by many
whose surgical needs have been met by the skills which it has helped to develop. I wish it well as I
confidently expect its readers to enjoy successful and fulfilling primary surgical practice.

Eldryd Parry, OBE, Visiting Professor & Honorary Fellow, London School of Hygiene and Tropical Medicine.
Chairman, Tropical Health Education Trust.
Formerly Professor & Dean of Medicine, Accra, Ghana; Addis Abeba, Ethiopia; and Ibadan, Nigeria.

DEDICATION

This book is dedicated to the world’s poor, so that when they need surgical help, they may get it, and it may
be done well.

ACKNOWLDGEMENT

Financial support for the initial collating of material for this edition was gratefully received from:
Asche Chiesi GmbH, Gasstrasse 6, 22761 Hamburg, Germany,
Deutsche Gesellschaft für Tropenchirurgie e.V. (German Society for Tropical Surgery), Erlangerstr 101, 07747 Jena, Germany.

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You must be humble; surgery is a craft that makes use of the scientific method of Popperian falsification.
The art of surgery consists of judgment and the beauty of an operation well done, done gently, with respect
for living tissue, for every cell, with reverence for form and function, carried out with compassion, always
remembering that the only justification for invading the body of another individual is the intent to restore
homeostasis.
Imre JP Loefler, Surgery in the Post-Colonial World (Rahima Dawood Oration).
E & Centr Afr J Surg 2002; 7(1): 53-8.

No person is so perfect in knowledge and experience that error in opinion or action is impossible.
In the art of surgery, error is more likely to occur than in almost any other line of human endeavour;
and it is in this field that it should be most carefully guarded against, since incorrect judgement,
improper technique, and a lack of knowledge of surgical safeguards may result in a serious handicap for the
rest of the life of the patient, or may even result in the sacrifice of that life. For the surgeon, perfection in
diagnostic skill is of equal, if not more, importance than operative skill.
Max Thorek, Surgical Errors and Safeguards in Surgery, JP Lipincott, USA. 1960

Any doctor who has worked in a developing country will not easily forget the widespread and pathetic
evidence of surgical neglect in the villages. Huge hernias and hydrocoeles, unsightly lumps on the faces of
women and children, and the compound fractures infected with maggots bear testimony to the failure of so
many countries to provide even a basic level of surgical care for their people.
Samiran Nundy, How might we improve surgical services for rural populations in developing countries?,
BMJ 1984; 39(10): 71-2.

Patients should be treated as close to their homes as possible in the smallest, cheapest, most humbly staffed,
and most simply equipped unit that is capable of looking after them adequately.
Maurice King, Medical Care in Developing Countries, Symposium from Makerere, Uganda. OUP 1967.

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Contents Chapter 5 The impact of HIV on surgery 72

Preface 1 5.1 Introduction.
5.2 Pathophysiology.
5.3 Transmission & prevention.
Chapter 1 The background to surgery 2 5.4 Sterilization.
5.5 Testing & visual recognition.
1.1 The unmet need for surgical care. 5.6 New pathologies & new strategies.
1.2 The surgical scene. 5.7 HIV & tuberculosis.
1.3 Twenty surgeons in one & medical superintendent? 5.8. Treatment of HIV.
1.4 Your surgical work.
1.5 Your patients.
1.6 Referral is mostly a myth.
1.7 The limits of this system of surgery. Chapter 6 The surgery of sepsis 93
1.8 Should you operate?
1.9 'Oh, never, let us doubt what nobody is sure about'. 6.1 'Where there is pus let it out'.
1.10 Creating the surgical machine. 6.2 Abscesses.
1.11 The surgical care of the poor. 6.3 Pustules (Boils).
1.12 Primary care imaging. 6.4 Carbuncles.
1.13 How to use these manuals. 6.5 Extradural abscess.
6.6 Infections of the orbit
Chapter 2 The surgical infrastructure 26 6.7 Peritonsillar abscess (Quinsy).
6.8 Retropharyngeal abscess.
2.1 The major theatre. 6.9 Dental abscess.
2.2 The minor theatre. 6.10 Parotid abscess.
2.3 Aseptic safe theatre technique. 6.11 Pus in the neck: Ludwig's angina.
2.4 Autoclaving. 6.12 Thyroid abscess (Acute bacterial thyroiditis).
2.5 Disinfectants & antiseptics. 6.13 Breast abscess.
2.6 Antiseptic surgery. 6.14 Axillary abscess.
2.7 Antibiotics in surgery. 6.15 Retroperitoneal abscess.
2.8 Particular antibiotics. 6.16 Iliac abscess.
2.9 Methods for using antibiotics. 6.17 Anorectal abscess.
2.10 When prevention fails: wound infection. 6.18 Periurethral abscess.
2.11 Post-operative pain control. 6.19 Prostatic abscess.
2.12 Records. 6.20 Abscess in the seminal vesicles.
6.21 Penoscrotal abscess.
6.22 Cellulitis.
6.23 Necrotizing fasciitis.
Chapter 3 The control of bleeding 45 6.24 Gas gangrene.
3.1 Assisting natural mechanisms.
3.2 Arterial bleeding.
3.3 Diathermy. Chapter 7 Pus in the muscles, bones, and joints 115
3.4 Bloodless limb operations.
3.5 Postoperative bleeding. 7.1 Pyomyositis.
3.6 Complications of blood transfusion. 7.2 The pathology of osteomyelitis.
7.3 Acute osteomyelitis.
7.4 Exploring a bone for pus.
7.5 Chronic osteomyelitis.
Chapter 4 Basic methods and instruments 54 7.6 Osteomyelitis of the humerus.
7.7 Osteomyelitis of the radius.
4.1 Appropriate surgical technology: the equipment you need.
7.8 Osteomyelitis of the ulna.
4.2 Scalpels and dissectors.
7.9 Osteomyelitis of the femur.
4.3 Scissors.
7.10 Osteomyelitis of the tibia.
4.4 Forceps.
7.11 Osteomyelitis of the fibula.
4.5 Retractors & hooks.
7.12 Osteomyelitis of the calcaneus & the talus.
4.6 Suture materials.
7.13 Osteitis of the cranium.
4.7 Needles & their holders.
7.14 Osteomyelitis of the jaws.
4.8 Suture methods.
7.15 Osteitis of the spine, pelvis & ribs.
4.9 Drainage tubes.
7.16 Septic arthritis.
4.10 Stapling devices.
7.17 Methods & positions for septic joints.
4.11 Miscellaneous equipment & materials.
7.18 Septic arthritis of the hip.
4.12 Instrument sets.
7.19 Girdlestone's operation (Hip excision arthroplasty).

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Chapter 8 Pus in the hands and feet 139 Chapter 13 The stomach and duodenum 243
8.1 The infected hand. 13.1 Peptic ulcers.
8.2 Subcutaneous hand infection. 13.2 Oesophagogastroduodenoscopy (OGD).
8.3 Apical finger space infection. 13.3 Perforated gastric or duodenal ulcers.
8.4 Paronychia. 13.4 Bleeding from the upper gastrointestinal tract.
8.5 Finger pulp space infection. 13.5 Surgery for a bleeding peptic ulcer.
8.6 Infection on the volar surface of the middle or proximal phalanx. 13.6 Hypertrophic pyloric stenosis
8.7 Web space infection. 13.7 Bleeding gastro-oesophageal varices.
8.8 Superficial palmar space infection. 13.8 Gastric outlet obstruction.
8.9 Middle palmar space infection. 13.9 Gastrostomy.
8.10 Thenar space infection. 13.10 Gastric carcinoma.
8.11 Dorsal hand and finger infection. 13.11 Gastric stricture.
8.12 Flexor tendon sheath infection. 13.12 Gastric foreign bodies.
8.13 Ulnar bursa infection. 13.13 Gastric volvulus.
8.14 Radial bursa infection.
8.15 Septic arthritis of the finger.
8.16 Difficulties with hand infection.
8.17 Pus in the foot. Chapter 14 Bowel inflammation & perforation 269
14.1 Appendicitis.
Chapter 9 Pus in the pleura, pericardium and lung 149 14.2 Inflammatory bowel disease.
14.3 Typhoid & small bowel perforation
9.1 Pus in the pleural cavities: empyema. 14.4 Necrotizing enteritis (Pigbel, Darmbrand)
9.2 Pus in the pericardium. 14.5 Amoebiasis: surgical aspects
9.3 Pus in the lung.

Chapter 10 Pus in the abdomen 155 Chapter 15 Gall-bladder, pancreas, liver and spleen 285
10.1 Peritonitis. 15.1 Introduction.
10.2 Subphrenic abscess. 15.2 Biliary colic.
10.3 Pelvic abscess. 15.3 Acute cholecystitis.
15.4 Empyema of the gallbladder
15.5 Cholangitis.
Chapter 11 Methods for abdominal surgery 174 15.6 Cholangitis caused by ascaris.
15.7 Other causes of cholangitis.
11.1 Before a major operation. 15.8 Cholecystectomy.
11.2 Laparotomy. 15.9 Obstructive (cholestatic) jaundice.
11.3 Resecting & anastomosing bowel: end-to-end anastomosis. 15.10 Liver abscess
11.4 End-to-side & side-to-side anastomosis. 15.11 Hepatoma (Hepatocellular carcinoma).
11.5 Stomas. 15.12 Hydatid disease.
11.6 Fashioning & closing stomas. 15.13 Pancreatitis.
11.7 Feeding jejunostomy. 15.14 Pancreatic pseudocyst.
11.8 Draining & closing the abdomen. 15.15 Pancreatic abscess.
11.9 After an abdominal operation. 15.16 Pancreas carcinoma.
11.10 Non-respiratory postoperative problems. 15.17 Surgery of the spleen.
11.11 Respiratory postoperative problems. 15.18 Splenic abscess.
11.12 Respiratory physiotherapy.
11.13 Abdominal wound infection.
11.14 Burst abdomen (Abdominal dehiscence). Chapter 16 Abdominal tuberculosis 313
11.15 Intestinal fistula.
16.1 Introduction
16.2 Ascitic type
Chapter 12 Intestinal obstruction 210 16.3 Plastic peritonitic type
16.4 Glandular type
12.1 The acute abdomen. 16.5. Tuberculosis of liver, spleen or pancreas.
12.2 Causes of intestinal obstruction. 16.6 Small & large bowel tuberculosis.
12.3 The diagnosis of intestinal obstruction. 16.7 Urological tuberculosis
12.4 The management of intestinal obstruction.
12.5 Ascaris obstruction.
12.6 Obstruction by bands & adhesions.
12.7 Intussusception.
Chapter 17 Lymph nodes & salivary glands 321
12.8 Small bowel volvulus.
12.9 Sigmoid volvulus. 17.1 Lymphadenopathy in HIV disease.
12.10 Reversing Hartmann's operation. 17.2 Fine needle aspiration.
12.11 Colorectal carcinoma. 17.3 Lymph node biopsy.
12.12 Caecal volvulus. 17.4 Tuberculous lymphadenitis.
12.13 Chagas megacolon 17.5 Salivary gland enlargement.
12.14 Mesenteric thrombosis 17.6 Lymphomas.
12.15 Other causes of intestinal obstruction. 17.7 Salivary gland tumours.
12.16 Ileus and obstruction following abdominal surgery. 17.8 Block dissection of inguinal lymph nodes.

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Chapter 18 Hernias 334 Chapter 22 Other obstetric problems 445

18.1 General principles. 22.1 Tests for foetal maturity.

18.2 Inguinal hernia. 22.2 Inducing labour at full term.
18.3 Difficulties with inguinal hernia. 22.3 Preterm labour.
18.4 Giant inguinal hernia. 22.4 Premature rupture of membranes & intrauterine infection.
18.5 Inguinal hernia & congenital hydrocoele in children. 22.5 Postmaturity.
18.6 Irreducible & strangulated inguinal hernia. 22.6 The malformed foetus.
18.7 Femoral hernia. 22.7 Breech presentation.
18.8 Strangulated femoral hernia. 22.8 More malpresentations.
18.9 Hernia of the umbilicus & anterior abdominal wall. 22.9 Prolapse & presentation of the cord.
18.10 Umbilical hernia in children. 22.10 Multiple pregnancies.
18.11 Paraumbilical hernia in adults. 22.11 Primary postpartum haemorrhage (PPH).
18.12 Epigastric hernia. 22.12 Secondary postpartum (puerperal) haemorrhage.
18.13 Incisional hernia. 22.13 Intrauterine growth retardation (IUGR).
22.14 Puerperal sepsis
Chapter 19 The surgery of conception 364
Chapter 23 Gynaecology 476
19.1 Maternal mortality.
19.2 Obstetric aims & priorities. 23.1 Pelvic inflammatory disease (PID).
19.3 Infertility. 23.2 Septic abortion.
19.4 Tubal ligation. 23.3 Abnormal and dysfunctional uterine bleeding (DUB).
19.5 Using a laparoscope. 23.4 Dilation & curettage (D&C).
19.6 Vasectomy. 23.5 Bartholin's cyst and abscess.
23.6 Urethral prolapse.
23.7 Fibroids (Uterine myomata).
Chapter 20 The surgery of pregnancy 378 23.8 Cervical & endometrial carcinoma.
23.9 Ovarian cysts & tumours.
20.1 Surgical problems in pregnancy. 23.10 Gestational trophoblastic disease (GTD).
20.2 Evacuating an incomplete or delayed miscarriage. 23.11 Uterine prolapse.
20.3 Termination of pregnancy. 23.12 Ventrisuspension.
20.4 Foetal death: retained miscarriage & intrauterine death. 23.13 Anterior colporrhaphy.
20.5 Recurrent mid-term miscarriages. 23.14 Posterior colporrhaphy.
20.6 Acute ectopic gestation. 23.15 Hysterectomy.
20.7 Chronic ectopic gestation. 23.16 Vulval carcinoma.
20.8 Angular (cornual) & cervical ectopic gestation. 23.17 Other gynaecological problems.
20.9 Abdominal gestation.
20.10 Ante-partum haemorrhage (APH).
20.11 Placenta praevia. Chapter 24 The breast 517
20.12 Placental abruption.
24.1 Introduction.
Chapter 21 The surgery of labour 401 24.2 Lumps in the breast.
24.3 Other benign breast conditions.
21.1 Two different worlds of obstetrics. 24.4 Breast carcinoma.
21.2 Obstetric anaesthesia. 24.5 Modified simple mastectomy.
21.3 Delay in labour. 24.6 Gynaecomastia.
21.4 Obstructed labour.
21.5 Managing obstructed labour. Chapter 25 The thyroid 528
21.6 Vacuum extraction (Ventouse).
21.7 Symphysiotomy (Pelvic release). 25.1 Introduction.
21.8 Destructive operations. 25.2 Hyperthyroidism (Thyrotoxicosis).
21.9 Which kind of Caesarean Section? 25.3 Thyroglossal cyst.
21.10 Lower segment Caesarean Section. 25.4 Physiological goitre.
21.11 Difficulties with Caesarean Section. 25.5 Colloid goitre.
21.12 Alternative methods of Caesarean Section. 25.6 Thyroid tumours.
21.13 Infection following Caesarean Section. 25.7 Thyroidectomy.
21.14 Elective Caesarean Section, trial of scar, 25.8 Other thyroid problems.
or Caesarean Section early in labour?
21.15 Birth canal injuries
21.16 Old 3rd degree tears.
Chapter 26 Proctology 535
21.17 Uterine rupture.
21.18 Vesicovaginal fistula (VVF). 26.1 Introduction.
21.19 Rectovaginal fistula (RVF). 26.2 Anorectal pathology in HIV disease.
26.3 Anorectal sinus & fistula.
26.4 Rectal bleeding (Haematochezia).
26.5 Anal fissure.
26.6 Perianal warts.
26.7 Anorectal carcinoma.
26.8 Rectal prolapse (Procidentia).
26.9 Haemorrhoids (Piles).
26.10 Pilonidal infection.
26.11 Other anorectal problems.

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Chapter 27 Urology 557 Chapter 29 The ear, nose, throat and bronchus 643
27.1 Equipment for urology. 29.1 Introduction.
27.2 Catheters & how to pass them. 29.2 Deafness.
27.3 Cystoscopy. 29.3 Otitis externa.
27.4 Haematuria. 29.4 Otitis media.
27.5 Bladder carcinoma. 29.5 Acute mastoiditis.
27.6 Retention of urine, 29.6 Foreign bodies in the ear.
27.7 Emergency (closed/blind) suprapubic cystostomy. 29.7 Epistaxis (Nose bleeding).
27.8 Open suprabupic cystostomy. 29.8 Rhinosinusitis.
27.9 Urethral strictures. 29.9 Nasal obstruction.
27.10 Impassable urethral strictures. 29.10 Nasal polyps.
27.11 Urethral fistula. 29.11 Foreign bodies in the nose.
27.12 Extravasation of urine. 29.12 Tonsillitis.
27.13 Urinary tract stones. 29.13 Naso-pharyngo-laryngoscopy.
27.14 Nephrostomy. 29.14 Bronchoscopy: inhaled foreign bodies.
27.15 Ureteric stones. 29.15 Tracheostomy & cricothyroidotomy.
29.16 Nasopharyngeal & maxillary antral carcinoma.
27.16 Bladder stones in adults.
29.17 Laryngeal carcinoma.
27.17 Bladder stones in children.
29.18 Leishmaniasis affecting nose & lips.
27.18 Urethral stones in children.
29.19 Bronchial carcinoma.
27.19 Prostatic enlargement.
29.20 Other problems in the ear, nose, & throat.
27.20 Open prostatectomy.
27.21 Bladder neck problems.
27.22 Prostate carcinoma.
Chapter 30 The oesophagus 678
27.23 Epididymo-orchitis.
30.1 Foreign bodies in the throat.
27.24 Hydrocoeles in adults.
30.2 Oesophagoscopy.
27.25 Testicular torsion.
30.3 Corrosive oesophagitis & oesophageal strictures.
27.26 Orchidectomy.
30.4 Oesophageal candidiasis
27.27 Undescended or maldescended testis.
30.5 Oesophageal carcinoma.
27.28 Testicular tumours.
30.6 Achalasia.
27.29 Circumcision.
30.7 Oesophageal rupture.
27.30 Phimosis & paraphimosis.
27.31 Meatal stricture.
27.32 Priapism. Chapter 31 The teeth and the mouth 688
27.33 Penile carcinoma.
27.34 Penoscrotal elephantiasis. 31.1 Introduction.
27.35 Kidney tumours. 31.2 Gum disease.
27.36 Schistosomiasis in the urinary tract. 31.3 Extracting teeth.
27.37 Other urological problems. 31.4 Impacted 3rd molar (‘wisdom’ tooth).
31.5 Cancrum oris (Gangrenous stomatitis, Noma).
31.6 Jaw swellings.
31.7 Cleft lip & palate.
Chapter 28 The eye 609 31.8 Oral tumours
31.9 Other dental & oral problems.
28.1 The general method for the eye.
28.2 Operating on an eye. Chapter 32 Orthopaedics 704
28.3 The red painful eye.
28.4 Loss of vision in a white eye. 32.1 Muscle & joint contractures.
28.5 Anterior uveitis: iritis, iridocyclitis 32.2 Managing leprosy paralysis.
& posterior uveitis: choroiditis. 32.3 Tuberculosis of bones & joints.
28.6 Glaucoma. 32.4 Tuberculosis of the spine.
28.7 Onchocerciasis (River blindness). 32.5 Tuberculous paraplegia.
28.8 Refractive errors: difficulties reading & presbyopia. 32.6 Back pain & lumbar disc lesions.
28.9 Disease of the neuromuscular system: squints, amblyopia, diplopia. 32.7 Managing chronic poliomyelitis.
28.10 Diseases of the eyelids & nasolachrymal apparatus. 32.8 Contractures of the hip & knee.
28.11 Proptosis (Exophthalmos). 32.9 Equinus deformity of the ankle.
28.12 Tarsal (Meibomian) cysts (Chalazions). 32.10 Club foot (talipes equinovarus).
28.13 Entropion. 32.11 Care of the neuropathic foot.
28.14 Destructive methods for the eye. 32.12 Foot ulcers.
28.15 Conjunctival carcinoma. 32.13 Tibialis posterior transfer for foot drop.
28.16 Retinoblastoma. 32.14 Painful hip or a limp in a child.
28.17 The eye in leprosy. 32.15 Stenosing tenosynovitis.
28.18 Other eye problems. 32.16 Ganglions.
32.17 Carpal tunnel syndrome.
32.18 The hands in leprosy
32.19 In-growing toenail.
32.20 Tumours of bone.
32.21 Other orthopaedic problems.

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Chapter 33 Paediatric surgery 759 Chapter 36 Thoracic surgery 836

33.1 Surgery in children. 36.1 Spontaneous pneumothorax
33.2 Neonatal alimentary tract obstruction.
33.3 Operating on a neonatal acute abdomen.
33.4 Omphalocoele (Exomphalos).
33.5 Disorders of the omphalomesenteric (vitelline) duct. Chapter 37 Terminal care & oncology 838
33.6 Anorectal malformations.
33.7 Hirschsprung's disease. 37.1 A task for every district hospital.
33.8 Hypospadias. 37.2 Controlling cancer pain.
33.9 Congenital abnormalities of the female genital tract. 37.3 Treating malignancy in a district hospital.
33.10 Neonatal jaundice. 37.4 Primary cancer chemotherapy.
33.11 Spina bifida & encephalocoele. 37.5 Looking after the AIDS patient.
33.12 Hydrocephalus. 37.6 Postmortem (autopsy) examination.
33.13 Congenital vascular lesions.
33.14 Other paediatric problems.
Chapter 38 Imaging 852
Chapter 34 Surgery of the skin and soft tissues 785 38.1 Radiology methods for the generalist.
38.2 Ultrasound methods for the generalist.
34.1 Hypertrophic scars & keloids. 38.3 Ultrasound in pregnancy.
34.2 Contractures.
34.3 Sebaceous (epidermoid) cysts.
34.4 Skin manifestations of HIV disease. Appendices 865
34.5 Nodules; basal & squamous carcinoma.
34.6 Melanoma. Appendix A, Grades of operation.
34.7 Leishmaniasis. Appendix B, Numbering & names.
34.8 Guinea worm infestation (Dracunculiasis) & Onchocerciasis. Appendix C, Abbreviations.
34.9 Tropical ulcer.
34.10 Kaposi sarcoma.
34.11 Mycetoma (Madura foot).
34.12 Elephantiasis.
34.13 Podoconiosis.
34.14 Filariasis.
34.15 Sarcomas.
34.16 Pressure sores (Decubitus ulcers).

Chapter 35 Vascular surgery 811

35.1 Varicose veins.

35.2 Peripheral gangrene.
35.3 Amputations in general.
35.4 Arm & hand amputation.
35.5 Above-knee (thigh) & through-knee amputation.
35.6 Below-knee amputation.
35.7 Ankle & foot amputation.
35.8 Aneurysms.

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Preface
The first edition of this work by Maurice King appeared in 1990 and has established itself as the gold standard of do-it-yourself
guides to surgery in the up-country hospital. Some 50000 hours of work went into compiling the mass of expert contributions from
many varied and far-flung individuals, all enthusiasts with a first hand indigenous experience of surgery in poor-resource
environments. The need for such a book has been amply justified, and 25 years on, its usefulness is in no way diminished.
Indeed, there is even greater urgency for such appropriate basic surgical guidelines to be disseminated in parts of the world where
people's access to surgery has been difficult or well-nigh impossible. To this end, it is envisaged that these manuals will be
translated into French, Spanish, Portuguese, Russian and Chinese, and also produced electronically as Compact Discs. Publication
on a freely accessible web-site will allow more readers access throughout the world.

Also, more is included on pathologies seen in different parts of the world, viz. Chagas’ disease in South America, Hydatid disease
in Asia, Schistosomiasis in Egypt, and so on. There will remain gaps, as different hospital environments will always differ hugely:
suggestions for alterations and inclusions will always be gratefully received, and incorporated in future editions, which can now be
updated electronically much more easily than heretofore.

The single most dramatic change in the practice of surgery in much of the developing world, and in Africa in particular, has been
the rampant inexorable spread of HIV disease since the early 1980's; this has seen the appearance of new pathologies, and the
requirement that new strategies are developed not only to combat its spread, but to deal with its effects. By the new Millennium,
antiretroviral medication was still seriously beyond the scope of most Government Health systems, but this is changing.
Whilst the advent of therapies to combat HIV effectively may still remain out of reach for very many, it will offer hope to the
young and those yet unborn that this scourge may be controlled, if only by encouraging victims of the disease to be tested.
Until recently, so much obfuscation around the disease, and slavish following of individualistic ideologies, has prevented much
community openness concerning this epidemic; it is fervently hoped that with cheaper and successful antiretroviral treatment,
the exceptionalization of HIV may disappear.

Much therefore of the changes since the First Edition have concentrated on the impact of HIV disease; however, other changes are
noted: for example, the inclusion of ultrasound and flexible endoscopy, which, though the equipment is expensive (it might be
sourced through donor agencies), it is highly cost-effective in diagnostic yield. Further, thyroid surgery is no longer excluded, as
its performance is considered no more complex than much else described. The inclusion of grading of difficulty of operations,
as mooted in the First Edition, has been carried out: this scale is inevitably idiosyncratic and is offered simply as a guideline,
especially for surgical technicians. Furthermore various procedures, which are in danger of being lost to the experience of Western
style practitioners and their trainees but are eminently useful in poor-resource settings, have been described in some detail.

It is rare that a book tells its reader what not to do, and what to do when things go wrong! This is such a book, whose aim,
essentially, is to encourage surgery in the districts and remote areas, if necessary by non-specialist, even non-medical, practitioners.
The realization that surgery is not an expensive luxury but a cost-effective intervention is slowly dawning on Health planners;
however, to remain viable, such surgery must remain relevant and relatively low-cost. It is estimated that 80% of surgery necessary
can be covered by 15 essential procedures. If even only these are mastered, the surgical contribution offered will be substantial.

The editors’ view is that laparoscopic surgery is not at this stage a generally viable adjunct, and is therefore not described.
Where special arrangements have been made, and a surgeon with appropriate skills is available, the benefits should not of course
be denied patients in rural environments. Nonetheless, the greater danger is that surgery is not done simply because of the
unavailability of highly trained individuals or of high-technology equipment, presumed essential, and this must on all counts be
avoided. Appropriate technology has been described, and inventions made known through the practical insights of many in poor-
resource settings has also been included. This must be further encouraged; indeed the principles thus discovered should be exported
to the so-called knowledgeable rich world, which groans under the ever-increasing cost and bureaucratic complexity of delivering
high-technology medicine.

It is the fervent hope that this second edition will bring relief and benefit through surgery to millions to whom it might otherwise be
denied. The fact that some 2 billion people in the world do not have access to any surgery must be seen as a scandal, and this book
will do its part in correcting this tragedy.

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1.1 The unmet need for surgical care

1 The background to
The attraction for patients and practitioners alike for surgical
surgery cures is that they are a ‘once-only’ phenomenon. For the
patient, surgery is therefore something than can reasonably
be borne stoically, and for the practitioner, surgery derives
You have just arrived at your hospital and have not yet intense satisfaction.
unpacked, when the ambulance arrives with a note
from the sister-in-charge to say that there is a patient Both can witness an often dramatic transformation of a
with a strangulated hernia waiting for you. critical to a normal situation. Health Planners are beginning
You have never done one, because you were left doing to realize that surgery is socially and economically
the paperwork when you did your internship and your cost-effective. This is true for elective as well as emergency
senior wanted to do as much operating as he could interventions, but especially so for trauma (the subject of
volume 2). Surgery need not be complicated, and should not
himself. So most of the time you assisted and were
be made unnecessarily expensive.
occasionally allowed to suture the skin.
All your seniors have now left and have gone into Surgically treatable diseases may not be as numerous as the
private practice, so there is nobody to help you. great killers of small children in the developing world:
If you refer this patient, he may die on the way. malnutrition, pneumonia, and diarrhea, but are rapidly
overtaking them! They nonetheless represent 11% of the
These manuals are dedicated to you. This personal reminiscence was
contributed by Dr Michael Migue of AMREF, as describing the scene for global burden of disease. However, surveys suggest that in
which these manuals are needed. Low & Medium Income Countries, 8% of all deaths,
and almost 20% of deaths in young adults are the result of
conditions that would be amenable to surgery in the
industrial world. If even very simple surgical services were
available two-thirds or more of these deaths would not have
occurred. What is more, for every person who dies of an
accident, there are at least eight who were permanently
disabled. Estimates are that maternal mortality rate (MMR)
is >340,000 per year, and probably <10% of mothers who
need a Caesarean Section get one done. Only 1 in 10 who
need an inguinal hernia repair get it done, and since a
strangulated hernia is almost always fatal unless it is treated,
this is a mortality of nearly 90%. For emergency
laparotomies the situation is worse: of 50 who need such an
intervention to save their life, only one gets it done!

These are just some statistics of the surgery that needs doing
and is not done. It is estimated that <3.5% of all surgical
interventions done worldwide are done in low-income
countries. Since most of these procedures will be minor
ones, it is probable that <½million major operations are done
ONE OF OUR READERS. You may have had very little surgical per annum in the these countries.
experience and yet have to operate on severely ill patients. In an emergency
you may even have to operate by the light of a hurricane lantern. The light All this unmet need means that there are many unnecessary
will attract insects, and these will fall into the wound, but even so they are deaths from strangulated hernias and obstetric disasters,
unlikely to influence the patient's recovery. However, a LED head torch will
be preferable in such situations, and ketamine anaesthesia is virtually always as well as from vesico-vaginal fistulae (VVF) and from
feasible! Kindly contributed by WHO. foetal cerebral injury or anoxia at birth. They illustrate the
fact that hospitals are only coping with a fraction of the
burden of surgical disease in the communities around them.
The result is that millions of people, whom surgery might
help, get no help. Too many people still die from obstructed
labour or obstructed bowel, or are disabled by untreated
osteomyelitis, or burns contractures, much as they were in
the industrial world a hundred years ago.

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If we wait till services are available to prevent the killing 1.2 The surgical scene
diseases of childhood, the simple surgical services described
here will not become available for a very long time. The countries of the third world and the surgical scene
They can do much to improve the quality of life of the poor. within them differ widely. Ethiopia and Paraguay,
for example, are about as different as two countries could be.
Although much of this manual has a rural orientation, Typically, the people of low-income countries are poor,
44% of the people of the developing world are now living in hungry, and rural, although they are rapidly migrating to the
towns, so the surgical care of the urban poor is almost towns. The population of sub-Saharan Africa is increasing at
equally important. As at 2010, 9 nations in Subsaharan an inexorable 3% annually, although in some countries there
Africa (Angola, Botswana, Cameroun, Congo, Gabon, was a negative growth rate due to deaths from HIV disease.
Gambia, Ghana, Liberia, Nigeria) have >50% of their Meanwhile its per capita food production and its already
population living in towns. There were no such countries in meagre gross national product even if increasing remains
Africa in 1950. Practically all South American and Far hugely unevenly distributed, whilst costs on the military and
Eastern nations have a majority of people urbanized. socially dislocating wars multiply. It is obscene that the
There is therefore an urgent need for ‘district hospitals’ in richest 1% own half the world’s wealth.
towns, leaving specialized care to the central institutions. One feature developing countries do have in common is that
Furthermore trauma presents an increasing burden of much of the surgery should be done in ‘district hospitals’.
morbidity and mortality in the developing world, and as the These typically have between 60 and 200 beds and are
success of its management depends mainly on early rapid staffed by 2-4 doctors, assisted by nurses and auxiliaries.
appropriate surgical care, this onus falls on the district Fortunately, the 'one-doctor hospital', which was common
hospital in the first place. until recently, is now unusual. Each hospital typically serves
about 150-250,000 people living in an area which may be as
Surgery has an importance in the public mind that medicine large as 3,000 square miles.
does not have. It is also the most technically demanding of
the tasks of a district hospital doctor or clinical officer, Over the world as a whole these hospitals range from the
and is thus a good measure of the quality of his medical excellent to the indescribable. At one end they provide care
education. If this has not been adequate, either because it which anyone would be fortunate to have, at the other the
never was adequate in the medical school, or because the few patients brave (or foolish) enough to enter them lie
quality of its teaching has fallen, he will be very loath to do largely untended. Nonetheless these hospitals are the local
much surgery, and may do none. This is why many rural focus of health care in the community and have an important
hospitals, and several district hospitals in some countries do place as such, as well as being a major employer of labour.
little surgery. When this happens, patients soon realize that it How much your hospital is valued by the Government can be
is no use going to such hospitals, with the result that they measured by whether the Minister of Health or his accolades
soon have empty beds. So if you see a hospital with empty would be willing to be treated at your institution, or whether
beds, one of the first questions to ask yourself is: “What is they will use scarce resources for treatment in a richer
the quality of the surgery here?” There is thus a qualitative country with ‘better’ facilities.
aspect to the unmet need for surgical care as well as a
quantitative one. If you work in a hospital in the middle or at the lower end of
this spectrum, expect to find your wards overcrowded, with
The constraints on the provision of surgical care are more than one patient in a bed. 'Clean' and infected cases
formidable, but some have succeeded in increasing their may not be separated, so that a patient with an open fracture
work-load and their operations tally despite rising costs and may lie next to one with a perforated typhoid ulcer.
scarce manpower resources. Your maternity ward is likely to be particularly
overcrowded, and resist all your attempts to decongest it.
Cultural reasons may make it impossible to restrict the
number of visitors to the wards. Defects in their construction
will make keeping them clean and tidy a major task.
Your equipment will be limited and poorly serviced.
When it does break down, it may take years to replace.
Trees may be so scarce that your staff have to go a long way
to collect firewood.
If your hospital is at sea level on the equator, expect to
operate at 300C in 95% humidity, your clothes wet,
and everything which can go rusty or mouldy doing so.
Only insects enjoy such conditions, and you will find plenty
of them.

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However, on occasion expect to find no water, no steam,

no linen, no gauze, no bandages, no sutures, no local
anaesthetics, no gloves (or only gloves with holes in them),
no plaster, (or only plaster that does not set) or no
intravenous fluids. When you need to prepare for a
laparotomy expect that no instruments have been prepared
beforehand. When you go into the maternity ward late one
night, be prepared for the last sphygmomanometer to be
missing. Try not to blame your staff too harshly,
they may not be responsible; and even if they are, their
families may be starving. Try to examine where things need
to be changed and call meetings to get these things done.
If you do have electricity, be prepared for it to fail at 3am,
just when you are in the middle of a Caesarean section.
Try not to blame cultural differences, and above all respect
Fig 1-1 THE SCENE IN A TYPICAL DISTRICT HOSPITAL IN your patients’ confidentiality.
AFRICA. This is somewhat better than the average conditions for Sub-
Saharan Africa at the time of writing. Note the blood transfusion
poster. You will see that there are several patients on traction, two with Even when you have your 'normal' supplies, you will not
long leg casts, and that one of the beds contains 2 patients. have solutions for parenteral nutrition, or plasma,
and probably no plasma expanders. You may, however, have
If your hospital is at high altitudes, expect problems with more than the teaching hospital: it too maybe without water,
sterilization (water boils at lower temperature) and with electricity, spirit, or linen! You may be cherished, supported,
smoke from numerous fires. praised, and congratulated by your Ministry of Health,
You may have to rely on locally trained staff with only or you may not. You may be in a health service which is
primary education who have not had training relating to the steadily improving, or in one which seems to be getting
idea of sterility. Most of them will experience considerable steadily worse, if that were possible.
hardship, and be so poorly paid that they will have to grow You may be in a culture which encourages you to be an
the food they need. Their ability to monitor a patient entrepreneur, or you may be in a system ready to direct
postoperatively on the wards may be so poor that you may blame if you do something wrong, and ignore the truth if you
be forced to assume that, once a patient has left the theatre, do nothing! Expect that you may be cut off from the rest of
he is on his own as far as recovery is concerned. the world for 4 months of the year. On top of everything
else, HIV may now be endemic in your district.
Your anaesthetic facilities will vary greatly. If you are lucky Finally, your greatest blow may be that your predecessor,
you will have 2 or 3 anaesthetic assistants, trained to do most who was promised that he would be posted to your hospital
of the methods described in Primary Anaesthesia. for only a short time, never ordered any stores.
You may have the services of well-trained surgical
technicians, who without formal medical training, can carry But you have great blessings. In coping with all this,
out most of the surgical procedures required very adequately. in creating and caring and leading and serving, you will have
You will rely on them more and more! Your laboratory done something that your colleagues in the more comfortable
facilities will usually be minimal. circumstances of private practice will never have done.
You are an all-rounder, and have one of the last remaining
Although HIV has made it much more dangerous in many opportunities to practice the totality of medicine, rather than
areas, blood transfusion should always be possible, if you some infinitesimal corner of it. Any lack of continuity of
can put enough effort into organizing it. Often, relatives will patient care will not be your problem. Sub specie aeternitatis
give blood for a patient, but for nobody else but don’t ignore (in the mirror of eternity), you are a hero and will surely be
the HIV risk just because the blood comes from a close recognized and remembered as such.
relative! You may have to try to make your own IV solutions
or rely on relatives to purchase essentials outside the You will need:
hospital. (1);A willingness to learn from the culture of your patients,
and learn their language. This will enrich you greatly,
So be prepared to find everything, or nothing. You may have whether you are a national from the urban elite or a
expensive equipment given by charitable organizations: foreigner, and will greatly increase their trust in you.
some of it may well be lying idle, because no-one knows (2);An almost pathological desire for hard work under
how to use it, what it’s for, or how to maintain it. conditions which are not conducive to it.
(3);An unfailing ability to improvise and make the best of
things.

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(4);The capacity to withstand prolonged periods of cultural If you subsequently move to work in the hospitals of the
and maybe financial isolation. If your morale is high, affluent world, you may well miss the sense of purpose and
so soon will be that of your staff also. Your patients will be achievement that you found when treating patients in low
grateful for anything you can do for them, and it is likely resource settings. Your experience, and your practical
they will not yet have learnt to litigate against you. knowledge may not be highly esteemed, or at worst ignored.
You will be shocked by the wastage of resources, and the
If you serve your hospital and the community round it for lack of a clinical acumen, that you have tuned carefully over
>5yrs, you will earn a unique place in its affections. much time and painful experience, that seems to count for
Just to prepare you, we describe the kind of situation you little in the corridors of modern high-technology hospitals.
may have to cope with.
However, no-one will be able to take away the pride that you
have done what so many of your colleagues wished they had
done, and the gratitude of so many of your patients, who,
without your help, would have suffered long or died.

1.3 Twenty surgeons in one & medical

superintendent?
As a doctor in one of the hospitals we have just described,
you are unlikely to find a fully qualified specialist surgeon
with 6-8yrs of postgraduate training. But somehow you have
to care for the sick in all of the 20 specialist fields shown in
the frontispiece, into which surgery has fragmented in recent
years. The chance of your being able to refer patients to
specialists is remote. There may be no maxillofacial surgeon,
or hand surgeon in the country, and if it is a small one,
there may not even be a specialist anaesthetist.
Even your own teaching hospital may lack the complete
range of specialists. Nor, despite present training programs,
is the situation in many countries likely to improve much in
the near future. Even your nearest regional hospital may only
have one or two general surgeons, or none at all!
But surgery will be only part of your work; you may also
have to be a physician, and a paediatrician, and manage the
Fig. 1-2 THE SCENE IN A TYPICAL POOR HOSPITAL. hospital as chief executive.
An improvised ward in a small hospital in Madhya Pradesh in the
1960’s. Most patients are accompanied by members of their families or
by friends. If they are away from their villages during the planting and This will be especially true if you are an emergency surgeon
harvesting season, they will go hungry. After Howard GR. Socio- flown in to help in a disaster situation, such as an
economic factors affecting utilization of a rural Indian hospital. Tropical earthquake; the first operation you are likely to have to do is
Doctor 1978;8(4):210-9 with kind permission. a Caesarean section!
DIDIMALA (4yrs) was severely burnt. You worked for hours to put up a
reliable drip and took great care to ring up for a bed in the referral hospital. As a leader, or even district medical superintendent, you may
When you pass by the ward 2 hours later, you find that she has indeed been have to deal with everything and everybody. When you
sent there by ambulance, but the drip is lying on the bed, and the vein is arrive, make note of what you see (you easily forget your
thrombosed. You ask, "Why is this?", to which you get the reply, "There first impressions and fail to improve things which could have
was no hook in the ambulance". been altered). Beware of the subtle temptations of
MARIA (6months) presented with intermittent vomiting and abdominal corruption: the bribes offered for preferential treatment,
swelling and was diagnosed as having intussusception. Unfortunately, the
first hospital she went to had run out of anaesthetic gases and so could not
the back-handers for unnecessary or sub-standard equipment,
operate. Her mother had to take her through three states stopping at four the requests for unsecured financial advancements from
hospitals before she found one which could anaesthetize her. hospital funds, the persuasive salesman for unrecognized
LESSON (1) Anaesthesia is often the limiting factor in surgery. (2) There is drugs, the falsifying of records and so on…. Do not get
no need to have to rely on a supply of nitrous oxide. (3) Some cases might bogged down in an office and let clinical work take second
not need anaesthesia if treated early (12.7). place: this should be your priority. Organize a regular
timetable for yourself and stick to it.

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The method of a good leader is to observe, listen, learn, So you will have to do your best in all these fields
discuss, decide, communicate, organize, encourage, facilitate simultaneously, as well as being 20 surgeons in one!
and participate. It is necessary to have a critique of your To help you we have collected from among the
activity: this is audit. Be sure to set goals, evaluate them, get armamentarium of diverse experts:
feedback, co-ordinate efforts of others, recognize (1);Some easier methods which you could use. Fortunately,
achievement and accept responsibility. Most problems will many of them, despite the fact that they are normally only
have as their root causes: poor leadership, poor relationships, part of an expert's expertise, are not too difficult.
poor pay, poor morale and working conditions, poor For example, the position of safety in a hand injury is within
administration, and poor supervision. How you handle a the competence of any doctor or technician.
crisis is the best test of your managerial skills; try to think (2);Those methods, either easy or difficult, which you will
beforehand what might go wrong, however, to avoid such a have to use to save a patient's life.
crisis. (3);Those difficult, disability-preventing but non-urgent
methods, for which you should refer a patient, but may not
Ordering supplies in advance and organizing repairs are most be able to, such as sequestrectomy for osteomyelitis (7.6).
important. Keeping good records is essential, both of
managerial decisions and patients. Do not forget aspects of Many countries do not even have enough general duty
hygiene, the use of toilets, disposal of garbage, the problems doctors to do all the surgery that needs doing, let alone
of overcrowding and relatives’ accommodation within specialists. Typically there is only one doctor for 50,000
hospital premises, and the problem of excessive noise! people, and only 4% of a severely depleted Gross National
Product is spent on Health Services. Many countries in the
Inevitably you will have to hold meetings, usually as world have recognized that essential surgery should be done
chairperson; set clear objectives and outcomes, set an by specially trained medical assistants (clinical officers),
agenda, keep a strict eye on time, and allow everyone to and several have trained them to do this. Such surgical
have their say, but keep folks to the point and avoid letting technicians are the backbone of surgical delivery in several
the subject drift. Afterwards make sure you get feedback. countries.

You will inevitably have to write death certificates, and How nice it was to see how well the Assistant Medical Officer (AMO) was
medical reports, and do much other paperwork. managing his tasks; he seemed to be well in control. He had done several
Caesarean Sections, 2 laparotomies for intussusception, some
Get a secretary to help you, and limit this sort of activity to a hydrocoelectomies, and fracture reductions. He was treating 3 cases of
particular short period in the day. Take care when disclosing fractured femur with skeletal traction in a very satisfactory way.
medical information: it may be confidential. His management of burns did not give cause for criticism. He had not had
sufficient experience of hernia operations, so we operated on 5 collected
Education is the key: daily morning reports, bedside cases together, after which he wishes to do them himself. To go to Kiomboi
teaching, grand rounds (especially for visitors), morbidity was an inspiration for our AMO training program. (Isaakson,G. Report of
visit to Kilamanjaro Medical Centre.)
and mortality (M&M) meetings and rehearsing critical care
practices should be the norm. Clinical audit is healthy: look We quote it to emphasize that, not only must much surgery
at, for example, rates of wound infection, success of skin be done by non-specialists, but that it is often excellently
grafts, incidence of HIV+ve patients, mobility scores for done by surgical technicians. Perhaps there is no such
femoral fractures, delays getting equipment repaired etc. teaching program in your country, and yet you are hopelessly
Remember, though, that M&M should not be an occasion to overworked. Try to train an auxiliary to do the simpler
apportion blame: it is a way to examine how you can avoid operations, such as hernias, Caesarean Sections and
exploratory laparotomies? Write out a simple-to-follow
errors of omission or commission, or poor judgement or poor
scheme so that they can follow a regular work-path.
technique. This will relieve your burden, and ensure the work carries on
when you are not there!
For you to keep up to date, do not miss out on your own
education: try to encourage specialists to visit your hospital, Remember that there may be a large turn-over of staff:
subscribe to journals (especially Tropical Doctor), establish don’t resent this but be welcoming of new faces & new
distance learning (by e-mail if possible), and promote a ideas!
hospital library. However, beware of spending excessive
time at workshops, which may leave your hospital stranded Beware ‘burn out’, where you get so exhausted and irritable,
and be little educational use to you. Try to visit your rural you cannot function properly. Take a break, leave the place
clinics and other hospitals in your district on a regular basis. and go on a well-deserved holiday, so you can come back
refreshed and revitalized (and bring some vital supplies
back)!

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1.4 Your surgical work This was a consecutive list of surgical cases seen over 3wks in a 50-bed
mission hospital in Mandritsara, Madagascar:

Of all your hospital admissions, 10-15% will probably be (i) a 9yr old girl with osteomyelitis of the tibia
surgical, but because operating is time consuming, and as (ii) 2 Caesarean sections for failure to progress
(iii) a 50yr old lady with intestinal obstruction & carcinomatosis
some patients remain in bed for a long time, surgery may (iv) a 24yr old lady with an ectopic gestation
take 30% of your time, and fill half your beds. How much (v) an 18yr old girl with gas gangrene of the uterus
you will do will depend on how good you are. Patients will (vi) a 48yr old man with an unresectable cologastric mass
travel hundreds of kilometres to a doctor with a good (vii) a 58yr old man with a pertrochanteric femoral fracture
(viii) a 46yr old woman with a large fibroid uterus
surgical reputation. A bad one will soon do little surgery. (ix) a 37yr old man with Fournier’s gangrene of the scrotum
(x) a 36yr old man with necrotizing fasciitis of the whole right leg
Look carefully at the ages and sexes of the patients in your (xi) a 16yr old girl with septic arthritis of the left shoulder
wards. When modern medicine first reaches a community, (xii) a 15yr old boy with a urethral fistula
(xiii) a 35yr old G9 P5 woman with pelvic impaction of the fetal head
the first patients to present are usually the men, followed by (xiv) a 45yr old lady with pericardial tamponade
the women and children. Only when medicine is well (xv) a 9yr old girl with 5 distal ileal typhoid perforations
established, will you see a proportionate number of older (xvi) an 8 month child with a huge 25cm sized hydronephrosis
women. You will see few hypochondriacs, but some may (xvii) a 93yr old man with a right inguinoscrotal hernia
(xviii)a 31yr old man with a plexiform shoulder neurofibroma
just come to see you because of your novelty value, (xix) a 56yr old lady with 3days of adhesive small bowel obstruction
and there are likely to be comparatively few repeat visits to (xx) a 17yr old girl with retained placenta for over 24hrs.
the outpatient department because travel is so difficult.
You will see many of the diseases that are common in the Fig 1-3 Table of surgical admissions in a rural hospital.
industrial world, but in different proportions, a major
difference being that so many of them present late (1.6). Always think whether what you can do to a patient will
probably benefit him; if you cannot refer him, or the distance
'Western diseases' such as aortic aneurysm, carcinoma of the is too great for him to reach the referral hospital alive,
colon, gallstones and varicose veins may not be very your choices are much clearer. Decide whether his problem
common at all in rural practice, but are diseases arriving in is urgent (and therefore needs your intervention) or whether
the cities. Urethral strictures, pelvic infections, fibroids and it can be alleviated by an operation within your scope
hernias are usually common, as are some diseases that are (even if something else has to be done later), or whether it
almost extinct in the industrial world: acute haematogenous can wait for the specialist.
osteomyelitis, for example. Try to get a specialist to visit you to teach and advise:
he may well enjoy a trip away from the daily grind!
You will probably see tuberculosis of the chest, lymph KALPANA (46yrs) presented with mild abdominal pain for several days,
nodes, abdomen, and bones, many manifestations of HIV severe for 4days, and diarrhoea with two loose stools tinged with blood
disease, amoebiasis and other 'tropical' illness. Sepsis is daily for a week. She had a tender, fluctuant mass in her right lower
frequent. quadrant, and a marked leucocytosis. At laparotomy she had a patchy
necrosis of her caecum with a localized perforation. A right hemicolectomy
was done for suspected necrotizing amoebic colitis (14.5). The operation
But you may seldom see carcinoma of the bronchus, or the was a nightmare. Her colon came to pieces in the surgeon's hands and there
thromboembolic complications of surgery that are so was gross faecal contamination. She died. LESSONS (1) Expect a different
common in the West; you may probably never see spectrum of disease from that you might be used to where a fluctuant mass
in the right lower quadrant may be most likely to be an appendix abscess.
diverticulitis. (2) Avoid doing a right hemicolectomy for amoebiasis if you can.
No branch of surgery will differ more starkly from that in the
industrial world than orthopaedics, where contractures and The late Imre J.P. Loefler, one of our editors, in a wide-
deformities are commonplace. ranging lecture on the failure of the medical profession to
deliver surgical care in much of the developing world, stated:
You may be presented with many kinds of operation to do, “You must be humble; surgery is a craft that makes use of
but 50% of your workload is likely to be in Obstetrics and the scientific method of Popperian falsification. The art of
Gynaecology. The rest will be divided almost equally surgery consists of judgment and the beauty of an operation
between sepsis and trauma, the nature of which will depend well done, done gently, with respect for living tissue,
on where your hospital is situated. for every cell, with reverence for form and function, carried
N.B. Trauma is discussed in Volume 2. out with compassion, always remembering that the only
justification for invading the body of another individual is
Unfortunately many times you will not be able to refer a the intent to restore homeostasis.”
patient (1.6). Never refer someone just to get him off your Loefler IJP. Surgery in the Post-Colonial World (Rahima Dawood Oration).
hands! Always think what would, in the current E & Centr Afr J Surg 2002;7(1):53-8.
circumstances (not in the ideal world) be the best for your
patient.

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Remember, it is not only possible, but usually mandatory, You are unlikely to be able to send patients for extensive
to perform surgery without every modern convenience. series of investigations before you start treatment.
Such surgery is by no means necessarily worse than that In fact you should rely more and more on your clinical skills.
done in a high-technology centre with every available Many patients will arrive with classic presentations or
gadget. advanced disease, and the diagnosis may be obvious.
However, we wish to present a guide on how to deal
BHEKUMUZI (10yrs) was lying in a District Hospital with an obviously
logically and effectively with patients without sophisticated
angulated fracture of the left forearm sustained when climbing a tree to fetch
fruit. When a visiting doctor came to do a surgical round, he asked when he technology. Do not fail to treat a patient simply because you
was admitted and was told, “Three days ago, just after it happened.” do not have the means you may be used to!
The reason given why the fracture had not been reduced was that no
radiograph could be taken because the Xray machine was not working!
Expect to find that the patient has other diseases also.
LESSON: It may seem obvious that you don’t need a radiograph to tell you
that an obviously angulated fracture needs reduction. Think whether you Studies in Nepal, for example, showed only 15% of
really need a laboratory to correct potassium loss in diarrhea, or an operations were done in otherwise healthy patients;
abdominal radiograph for a gross sigmoid volvulus, or a CT scan for a head in Zimbabwe over 30% of operations were done on patients
injury.
with HIV. So expect your surgical patients to be poor,
malnourished, immunosuppressed, anaemic, malarious,
1.5 Your patients tuberculous, or worm-ridden, or all of these things.
These illnesses make a patient weak, wasted and a poor
In many of the villages of the developing world, the burdens operative risk. Anaemia increases the risks of surgery, and in
of chronic disadvantage, poverty, ignorance, and insanitation some communities the average haemoglobin may be only
are the background to life. A surgical disease on top of this 8g/dl. Some patients may still be walking around with 4g/dl
may be the last straw. or even lower. Apart from little breathlessness on the hills of
Nepal, one 12yr old girl with a Hb of only 2g/dl had no other
As a result, patients often present late. If yours is a really complaints. So try to prepare your patients for surgery before
disadvantaged community, tapping a hydrocoele may yield you operate, especially if the cause is readily treatable. But
litres rather than mls of fluid. An elephantoid scrotum may beware the dangers of blood transfusion (5.3).
have progressed so far that it hangs to the ground (27.34).
If a patient has a urethral stricture, he may leave it until he Pain and disability are unlikely to rate highly when there is
has multiple fistulae or massive extravasation (27.11). rice or maize to be planted, or when there are festivities and
If he has carcinoma of the penis (27.33), he may wait until holidays. Although the local economy may be poor,
much of it has been eaten away. Most carcinomas of the certain obligations may be compelling.
breast (24.4) and cervix (23.8) present too late for any hope
of cure. Some cultural objections may exist, to orchidectomy,
for example, and may be so firm that a patient is unlikely to
Too often, patients only present when complications have agree. Mastectomy or colostomy may be similarly abhorrent.
made their lives unbearable. When even the struggle to stay
alive may be a losing battle, the fact that surgical disease is
normally treatable is irrelevant.

There are usually good reasons why a patient presents late.

The family may have had no money for the operation or for
transport, or there may be no transport. Perhaps it is the plan-
ting season, or there is nobody to look after the children or
the goats? Perhaps the disease is painless, and symptoms can
be tolerated, so that illness remains unrecognized?
Perhaps the tolerance to pain, disability, deformity, and
misery is so high that help is only sought as a last resort?
A patient may only come to you when he has exhausted local
remedies and the services of traditional practitioners.
He may not come to you because he doubts whether you can
provide any assistance, or that he can afford it.
Transport, which may have been difficult before the rainy
season, can become an insurmountable problem when roads
Fig. 1-4 A PRIVATE WARD in a rural hospital. For a village family an
become quagmires, and rivers even more perilous. illness is more than a biological disorder: it may be a social and
Acute surgical emergencies, in particular, may only come economic crisis. After Howard GR. Socio-economic factors affecting
when patients are in the direst straits. utilization of a rural Indian hospital. Tropical Doctor 1978;8(4):210-9 with
kind permission.

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Death is the great enemy of doctors and evidence of our Although 'referral systems' exist in all health services,
failure. But a patient may have faced up to his own mortality the difficulties put in a patient's way are often
long before you have, and may not always share your view. insurmountable. Unfortunately, for many patients referral is
He may have learnt to live with death since childhood, a myth. In many resource-poor countries the possibilities for
and both his own attitude to it and that of his closest relatives referral appear to have got worse during the last decades
may be very accepting. Never lie to a patient when you know rather than better. Too often, there is just no petrol for the
he is dying: he probably knows it also, and realizes you hospital's ambulance to take a patient to a referral hospital,
know it too! or no money to buy it; furthermore the roads may be
impassable; he may not have money to pay the referral
One of the greatest mistakes you can make is to offer a hospital fees, or the bribes necessary to gain admission, and
useless operation, which will use up much of his own he may be very reluctant to travel so far away from home.
resources and those of the hospital in an unsuccessful Alas, in many countries the future does not seem any more
attempt to produce a cure. Theodor Billroth, a pioneer of hopeful.
surgery, famously commented, “To operate without having a
chance of success is to prostitute the beautiful art and science Only too often a patient reaches a referral hospital with great
of surgery.” In some cultures it is important for a patient to difficulty, only to return no better then he went.
be buried at home, so consider sending a terminally ill Because there are so many uncertainties, assess the chances
patient home early while he can still travel. for each patient individually. Try to find out what happens to
each of the patients you send. Just what cases is it useful to
refer, how, when, and to whom? If there are referral services,
be sure to use them, both to refer patients properly and to
1.6 Referral is mostly a myth learn from yourself.
A patient with a surgical disease has first to refer himself to In the pages that follow we assume that you cannot refer
you, and if you cannot care for him, you must consider the patient. There may be procedures you do not feel
referring him to someone else. Referral onwards from a confident to do; obviously if you do have the opportunity for
community health worker (CHW) normally takes place at all referral, use such help. Consider carefully if the patient may
the five steps (1-5). Although surgery is done in other parts end up worse off than if you had not intervened.
of this system, we are concerned with the district However, do not back out of a life-saving procedure through
(or mission) hospital, and the critical referral steps from false modesty. This volume exists to help you in just such a
C to D and from D to E. situation.
Do not overburden the referral hospital with minor cases;
take the opportunity to spend time there to
learn surgical procedures if you need more
experience.
The important factor is the degree of urgency
that exists: balance this against the feasibility
of referral.

N.B. Some surgeons working in referral

hospitals have a false idea of the practicalities
of referral. They see only the ‘tip of the
iceberg’ (or the ‘ears of the hippopotamus’),
the patients who reach them successfully:
they may think that referral is easier than it is.

Fig. 1-5 THE REFERRAL SYSTEM.

Each of these steps in the referral chain has its
difficulties. A, from the patient’s home to the
community worker. B, from the community worker to
the health centre. C, from the health centre to the
district hospital. D, from the district to the provincial
hospital. E, from the provincial to the teaching hospital.
The histograms show a typical change in the total
annual number of operations done at each stage in the
referral chain in 1980 and 2000. Little surgery is now
done in many of the district hospitals, but it is often not
being done in the provincial or national hospitals either.

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There are however certain cases which referral hospitals Unfortunately, the provincial surgeon had left the previous day to attend a
planning meeting at the Ministry of Health. He would not be back for 2days.
should accept without question, and district hospitals should
The provincial surgeon returned and saw him, but decided that the training
know what they are. Such, for example, is the management had not prepared him for posterior exploration of the humerus, plating the
of intestinal fistulae (11.15). fracture and perhaps secondary suture of the radial nerve. Also, he had no
6/0 monofilament. So Patson was given a bus warrant, and a note to the
orthopaedic surgeon in the teaching hospital in the capital city.
Remember, referral hospitals also have their problems:
Unfortunately, he had no money, no food, and no clean clothes for the
(1) They may be overcrowded with simple cases that you journey, so he went home. The Land Rover had been partly dismantled by
could care for in your district hospital. thieves, but his partner had towed the wreck back to the village, and hired a
(2) When the time comes to discharge a referred patient who lad to help him with the fishing. The family were already deeply in debt.
They debated whether he should go 800 km to the capital, but the limp wrist
cannot go home unaided, they may be unable to send him
decided them. He started on the long journey with a pack of food, a few
there because they cannot contact the rural relatives. clean clothes, and a bus warrant, but very little money.
(3) Their system of communicating information may be very Four days later he arrived at the orthopaedic clinic on a Friday. He had no
longwinded, so you may not get proper feedback unless you appointment, and the surgeon to whom the note was addressed had held the
clinic on the previous day. The harassed sister, busy with another clinic,
yourself enquire: that is why direct contact is so useful!
found that he had no relatives in the city, and no money, so she sent him to
the orthopaedic ward in the hope that they might have a bed for him over the
One of the purposes of these manuals is to make sure that weekend. They did.
any surgery that can be done in a district hospital is done On Monday the surgeon saw him. The wound had healed and he was fit for
surgery, and the necessary screws, plates, adhesive drapes, and sutures were
there, so that referral hospitals can fulfil their proper
in stock. But there was a three months’ waiting list, so he had to wait 8days,
function, and life-saving surgery is not deferred till after a even for operation as a semi-emergency. A silent cheer went up from the
long journey to the referral centre. Another purpose is to hospital staphylococci, as they began to colonize the skin of this provincial
train cadres (not necessarily doctors) to acquire special skills patient.
His radial nerve was freed from compression in its spiral groove, and the
to deliver surgical services relevant to situations.
fractured humerus was successfully plated. Two weeks later he returned to
the provincial hospital with suggestions for physiotherapy (a 2day journey
REFERRAL: IS IT WORTHWHILE? for each session) and instructions to return in 1yr for removal of the plate.
He was lucky. He was one of the minority for whom the referral system
'worked'. The radial nerve palsy recovered. A friend paid for nearly 4wks in
The chances of being able to refer a patient vary greatly,
a teaching hospital, and 1600km in transport. He was in debt, and the family
and are apt to change. They depend on the answers to these were hungry, but he did not have to sell the boat, or the remains of the Land
questions: Rover. It could have been much worse.
(1) Does he have a disease for which the referral hospital has
TOPNO (41yrs) fractured his ankle in a bus accident. The very competent
no effective treatment (e.g. hepatoma or advanced HIV
doctor who saw him had learnt that difficult ankle fractures should be
disease) or equipment (e.g. advanced osteoarthrosis of the referred. He could manipulate fractures, but he thought that an expert would
hip needing hip replacement)? do better, so he sent the patient with a letter to the referral hospital 70km
(2) Does he have a condition (e.g. cleft lip & palate) best left away. After a long journey, the patient arrived too late at the fracture clinic.
He was able to reach the next fracture clinic in time, only to find that the
till a later date?
surgeon was away at a conference. So he hung around hopefully for some
(3) Does he have a condition which will kill him before he days, but in the end he was advised to return to the original hospital.
gets there (e.g. ruptured spleen) or be untreatable by the time Meanwhile, he had had no treatment except the original 'first aid' plaster.
he gets there (gastroschisis)? When he eventually returned to the doctor who first saw him, the fracture
had partly united in a very bad position. It was now too late to manipulate
(4) Will he be able to get there and look after himself when
him, so he now has a stiff painful ankle and is waiting to have it fused.
there? What about his family? LESSON A patient may be better in your hands, if you learn those
(5);Will he be sure of getting any better treatment than procedures that you can reasonably do, in your own set-up.
yours? Try to contact the surgeon for advice before sending Jellis JE. Chairman’s Address, Proc Assoc Surg E Africa 1981;4 53-6
the patient, especially if distances are long and the case is not
an emergency. ASSESS EACH PATIENT'S CHANCES OF
EFFECTIVE REFERRAL
PATSON (49yrs) was in a Land Rover when it rolled over in deep sand,
causing an open fracture of the right humerus and injuring the radial nerve. Make sure you know the specialist’s timetable, and his
He was still able to walk, so he eventually reached a district hospital, where contact details including mobile phone numbers. You can
the wound was carefully toileted, and left open for delayed primary suture.
often use the messaging system on mobile phones better than
The radial nerve injury was recognized, the arm was put in a collar-and-cuff
sling, the wrist in a cock-up splint, and he was asked to return in 48hrs. The the voice; with newer mobile phones, you can send pictures
wound being clean, it was closed. So far he had received ideal treatment. of a radiograph, histology slide, or even a patient’s lesion.
It was decided to refer him to the provincial hospital 40 km away, across a Beware, though, of possible leaks of confidentiality.
river and a flood plain, 8mins by air, a day by boat, or 2days by Land Rover.
There was no radio, and the telephone was not working, so there was no
Can the patient get himself to the referral centre? In some
way of telling the provincial surgeon that he was coming. He was able to get
a seat on a barge and was in the provincial capital 24hrs later. It was dark districts, for example, the roads and airstrips are closed for
but he was able to find a relative with whom he could stay the night. The weeks at a time during the rainy season.
next day he sat in the outpatient queue and handed the slip to the medical Is he prepared to leave the family and the fields or the job?
assistant.

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Has he or the hospital got money for transport and for We have tried to serve all your needs.
lodging when he gets there? Often, neither of them have. Although learning something from a book is not for many as
If he does arrive, will he arrive on the right day, find the way good as learning it first hand from a good teacher, the very
to the right clinic, wait in the right queue and be seen and raison d’être of this text is to provide relevant information in
admitted? Will there be an empty bed? Will the surgeon you a situation where you have no such teacher! These books,
send him to actually be there when he arrives, or will he though, are of no use if they are kept unused on the
have gone on holiday, or to a conference in America? bookshelf!
Investigate him first if you can, and state the procedure that
you think he needs. If a biopsy is necessary, do it, and refer As books are expensive, we have endeavoured to make this
him with the report. Often this takes time to obtain or text available electronically as a compact disc, and on the
may have to be sent to the referral hospital anyway. internet, which we hope will further disseminate the
You might then send the patient with the biopsy specimen accumulated wisdom gathered herein.
already taken. If referral is urgent, do not wait for the report,
but give sufficient details so the report can be traced. It has not always been easy to distinguish the tasks which are
obviously impossible for you (oesophageal atresia for
Inform the surgeon that the patient is coming. Make sure that example), from those which may be possible (duodenal or
the patient knows exactly what to do, and where to go when jejunoileal atresia). We have had to balance benefit,
he arrives. Send a careful letter with him, including all risk and urgency. This has led us to include methods for
necessary information. removing the prostate, for example, but not a meningioma.

If there are any particularly good referral facilities, such as We have tried to grade the difficulty of operations described.
those for artificial limbs, for example, be sure to use them. They are included in this edition. If you can refer the more
difficult cases and the patient is likely to obtain a better
Finally, do not refer patients unnecessarily. No surgeon likes result if you do so, this is obviously preferable.
to be sent plantar warts. We have stressed, though, that some operations are only for
the careful, caring operator. These include Girdlestone's
arthroplasty (7-21), closure of a Hartmann’s procedure
(12-15), Roux-en-Y anastomosis (15-12), and closure of a
1.7 The limits of this system of surgery meningomyelocoele (33-15).

Detail, especially in surgery is important, but you can get Although the common conditions may comprise perhaps
bogged down in details. The quotation, “Le bon Dieu est 60% of your work, the rest will include many rarer ones.
dans le detail” (God is in the details), attributed to Gustave In aggregate, the rarities are common. So we have tried to
Flaubert, the French writer (1820-1880), must be balanced describe as many of the comparative rarities as we can, in the
by the German proverb, “Der Teufel steckt im Detail” hope that you will find about 98% of the conditions you
(The devil hides in the details)! could hope to treat surgically described here. The edges of
this large collection of appropriate methods are inevitably
In view of the common impossibility of referral, we have blurred, and it has not been easy to know which rare,
tried to describe everything that you, our readers as a whole, or which difficult procedures we should include.
might have to do; both the emergency procedures and the For example, you will find much on HIV-related pathology
less urgent elective cases. (5.6), and there is even mention of cystic hygroma (33.14).

As you will see in the next section, you individually, should We shall probably be criticized for including
not necessarily do everything we describe. We take for oesophagoscopy (30.2) and bronchoscopy (29.14), and some
granted that personal tuition from an expert is the best way cancer chemotherapy. But it is better to include slightly too
to learn anything. But, what if there is no expert? much rather than slightly too little - there is no obligation for
A manual is surely better than nothing. you to do things you do not feel able to do, but a crisis may
force your hand! Thyroidectomy (25.7) is our tour de force,
Somehow, we have had to find a balance, so we have and the great detail with which we have described it should
considered each procedure on its merits. Our task has been enable our more experienced and caring readers to do it.
made no easier by the wide range of the abilities of our Some methods, such as methods of haemostasis,
readers. You may range from being a highly trained surgeon, are classical, in that no textbook of surgery would be
doing unfamiliar operations for the first time, to an complete without them. Inevitably, some parts of the 'system'
inexperienced technician doing your first job. are tidier than others.

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We have excluded all procedures which appear too Would his operation be better done elsewhere? On the whole
sophisticated, but the range of facilities available is always we think that for every doctor who operates when he should
very wide. In some cases we may have made false not, there are many more who do not operate when they
assumptions. We have often assumed that you have an X-ray should. So one of our aims has been to get more surgery
facility, and ultrasound for example. done, on the correct indications! The mature surgeon is one
who knows when not to operate! On the other hand, if you
Uncertain sterilizing procedures, and limited nursing care are always too cautious, you will never learn and some of
have also guided our selection. your patients will never benefit. Remember to keep records
(2.12).
Although we write mostly for hospitals which are short of
both money and skill, there are some, such as those run by So beware of what Max Thorek's describes as furor
mines and plantations, or supported generously by outside operandi, the furious urge to operate, and ask yourself these
agencies, where money is less scarce. These might be able to questions before you do so:
procure even comparatively expensive drugs for cancer
chemotherapy, for example. For them all the equipment we What will happen if you do not operate? If a patient is
list (even bronchoscopes and oesophagoscopes) should not likely to die or become disabled if he is not operated on
be a problem. However, beware the notion that expensive quickly, you will have to operate. We have therefore
methods are necessarily the best! included all the more practical emergency operations,
whether difficult or not. For example, you must drill
Overall: immediately for acute osteomyelitis, but a patient who needs
(1) We have tried to describe a system of practice which a sequestrectomy for chronic osteomyelitis can wait.
includes all the basics, but is ahead of the practice of many
district hospitals, so that even comparatively advanced ones How difficult is the operation?
have something to aim for. At least three factors determine this:
(2) We have tried to cover most of the range of the 'general (1) your technical knowledge,
surgeon' working in the districts. (2) your experience,
(3) We have tried to describe this system in complete detail, (3) your skill. We can provide you with the knowledge, and
and in doing so would agree with both the quotations with bring you some of the experience of other people, but only
which this section starts. practice will improve your manual skill. A score is given for
(4) We have in our mind's eye a concept of 'quality' at the your guidance. Grades 1.1-5 describe simple procedures that
district hospital level; even simple things can and should be you will definitely have to master. Grades 2.1-5 describe
done well. straightforward operations without serious difficulties or
(5) We have tried to give guidance when things go wrong. complications that would not pose much of a problem for
basic surgical trainees. Grade 3 represents more difficult
This last is most important. Many texts tell you what you operations, with increasing complexity up to 3.5.
should do (in the author’s view); few explain what to do with
complications. If you can correct these, you will often avoid Those procedures of even greater difficulty may be
a catastrophe and gain much satisfaction. You will also build mentioned in passing but not described, as they are thought
a base of great wisdom for the future. to be unsuitable for the situations pertaining where this book
will be useful.

1.8 Should you operate? How good is your post-operative care?

It may be a good idea to have a special ward for the serious
Although the era of ‘furor operandi' has passed, one still has almost daily post-operative cases: the advantages are concentrating staff
evidence of the disastrous effects of major surgical procedures, attempted where they are needed, giving them experience and training,
lightly by young, or even inexperienced older, surgeons. The author would and making it easier for you to visit and monitor these
in no way dampen the ardour of the neophyte, or check the ambition to
patients. If you can separate a section or unit for intensive
acquire skill. Still, it is well to suppress the feelings of cocksureness and
egotistic pride. (Thorek M, Surgical Errors and Safeguards, JB Lipincott, care (ICU) for the really serious cases (11.9), so much the
1932) better.

Whether or not you should operate on a given patient will be How safe is the operation? What disasters may happen?
the most important question you will have to answer. Little untoward can go wrong with draining most abscesses,
Put yourself in the patient’s place. What would you like to or manipulating most fractures, but disaster lurks if you
happen if you were the patient? Several factors will decide to close an intestinal fistula, dilate a difficult urethral
influence your decision. We have already discussed one of stricture or do a block dissection of the groin.
them: can you refer him?

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Do you have the instruments, materials, & staff needed? WRITE THESE RULES UP IN YOUR THEATRE:
Even if you do not, you may be able to improvise.
Check that the electricity is working, the blood can be cross- RULES ABOUT DECIDING WHEN TO OPERATE:
matched, the necessary staff are present. Do not be over- (1).You must be certain of the indication to operate, even if
ambitious initially with staff whose expertise you do not it is only exploratory.
know; assess the capability of the hospital to handle certain (2).When life is in danger, take risks and act fast.
procedures. Try to build on your experience, and teach the (3).If a case is hopeless, be prepared to say: “No!”
staff (and yourself) accordingly. Check the instruments, (4).Do not do difficult elective surgery, especially if the
and equipment before you start. Discuss the case with your expected outcome is likely to be of limited value to the
anaesthetist colleague (if any). Is he experienced enough to patient.
administer the GA you require? Is there an alternative? (5).Take trouble to make sure the time is correct to operate,
and all the preparations for surgery are in place.
Are you yourself inclined to operate too readily, or not
readily enough? RULES BEFORE OPERATING: Inform the theatre of
your operation list well in advance, if possible. Book your
Cultural attitudes to operating vary. In Indonesia, for children, clean cases and diabetics first.
example, the common failing is to be too timid, and not to (1).Go over the history, examination and investigations
operate when necessary. The reverse is true in some parts of yourself to confirm it is the right patient: ask him his name
Africa, where inexperienced operators are much too bold. yourself! Confirm the correct diagnosis, and that the need for
So be aware of your own personal and cultural bias and try surgery still exists.
to correct for it. Do not operate out of bravado! (2).If there is a lump, make sure you can feel it. Mark it.
Make sure the bladder is empty.
Is the reason for operation unclear? (3).Ask the patient what operation he expects to be done and
If the indication is vague, wait! Do not be dragooned into explain the nature of this operation, its purpose and
operating by enthusiastic nursing staff or insistent relatives. consequence to the patient: this is informed consent.
Treat the lowliest patient the same as an important politician. You need not scare him or confuse him with medical jargon,
but do not keep him ignorant and make sure he and the
What is the known or probable HIV status of the relatives understand. Use diagrams, stories or even cartoons.
patient? (4).Mark the side to be operated upon with indelible ink.
Take a social and sexual history. Look for tell-tale signs of (5).Make sure the patient bathes the night before surgery,
immune deficiency (5.6). and that especially the operative area has been cleaned.
N.B. You should try to move toward routine HIV-testing Trim his nails, clean the umbilicus, scrub the feet,
especially if antiretroviral treatment is available. remove studs and jewelry. (There is no need to remove all
nail varnish or bangles and threads of religious or cultural
What is the general condition of the patient like? significance, but take down an elaborate hairstyle which may
(1) Check the Hb level (and sickle test if this is common in prevent extension of the neck.) Never use blunt razors to
your area), and the level of malnutrition and dehydration. shave the skin: do minimal shaving. Remove any loose or
(2) Assess the respiratory reserve (11.13). false teeth.
(3) Measure the Peak Expiratory Flow if you can. (6) Check for any allergies.
(4);Can you improve the hydration or nutrition (7).Check that the patient is starved for 4hrs (less for babies),
pre-operatively? but warm, well-hydrated and fit for a GA, fluid-loaded for a
Assess the risks of complications. Remember you will cut, spinal anaesthetic, and that diabetes, hypertension, asthma,
saw, burn, bruise, traumatize and violate your patient, epilepsy, and coagulation are controlled. Do not starve
exposing his tissues to the cold and hostile external patients for long periods waiting for theatre!
environment, spilling his blood and body fluids but the Make carbohydrate drinks available up to 2hrs pre-op to
patient’s own healing mechanisms need to repair the avoid hypoglycaemia. Remember deep vein thrombosis and
damage. You can only assist this process. antibiotic prophylaxis if indicated.
Decision. If you have difficulty knowing what to do and can (8).Check that blood is cross-matched if required, and blood
contacto anyone who might know, do not hesitate to do so. results available.
Try to invite a surgeon to your hospital for a period to give (9).Make sure especially that suction, laryngoscopes,
you instruction first-hand. airways, ambu-bags, masks, endotracheal and nasogastric
tubes, stethoscope and diathermy are available. Make sure
Have this book available in theatre. the patient comes to theatre with the notes, investigation
results and radiographs, and properly signed consent for the
proper procedure (with the correct side, if any, noted).
(10).Familiarize yourself with the operation to be performed
if you are uncertain of any details.

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SPECIAL CONSIDERATIONS. If it is a minor operation and the patient is eating

Some patients are taking routine medicines: do not stop these normally afterwards, restart the insulin at the normal time.
just because they are starved before operation! This applies If he is not, start a sliding scale: you may need to adjust the
especially to anti-hypertensives, bronchodilators, steroids, sliding scale insulin doses if these were previously high so
anticonvulsants, anti-Parkinsonian drugs, cardiac that the total given per day for a level 4-8mM equals the
medication, anti-thyroid drugs and thyroxine. normal total pre-operative dose, viz.
For a patient on 30 IU am, and 18 IU pm,(total 48 IU),start with 48 divided
Steroid-taking patients should get extra amounts: add
by 4 (number of times glucose is checked/day) = 12
100mg hydrocortisone at the start of a major operation and Glucose Level Soluble Insulin needed
then reduce slowly: 100mg tid on day 1, 50mg tid on day 2, 0 - 4 mM 0 IU
25mg tid on day 3. 4- 8 mM 12 IU
(NB. 100mg Hydrocortisone = 25mg Prednisolone= 4mg Dexamethasone). 8-12 mM 16 IU
12-16 mM 20 IU
Oral contraceptives: stop these 1month before a major 16 -20 mM 24 IU
operation, especially involving the pelvis, where she is not >20 mM 28 IU
ambulant immediately postoperatively. Advise about
If it is a major prolonged operation, use 16 IU soluble
alternative barrier methods or you may be blamed for an
insulin with 20mmol KCl IV in 1 litre of 5% Dextrose at
unwanted pregnancy!
100ml/hr during the operation provided the blood glucose
level is >4mM and check it 2hrly. If it is >16mM, add
Anticoagulants: stop these 3days before a major operation; another 16IU soluble insulin to your infusion.
an INR <2 is ideal if you can measure it. Avoid spinal After the operation, continue with a sliding scale.
anaesthesia and the use of tourniquets.
If ketoacidosis is present in an emergency, administer 10IU
Antidepressants can give problems (e.g. tricyclics) with soluble insulin IV and, 10 IU IM immediately, and then 6 IU
anaesthesia: stop these 2wks before a major operation. IM hourly; infuse 5lNormal saline, the 1st in 30min, the 2nd
with 20mmol KCl in 1hr, and the 3rd to 5th with 20mmol KCl
Alcohol: many people drink large quantities of alcohol. in 2hrs each. Then when the glucose level is <15mM, start a
This may affect the liver, and cause slow metabolism of sliding scale régime, and alternate Normal saline with 5%
anaesthetic agents, bleeding disorders, and produce dextrose.
post-operative withdrawal symptoms. You may need to sedate an alcoholic with large doses of
diazepam, chlorpromazine or chlomethiazole, especially
Diabetics need careful handling. Check glucose levels post-operatively.
regularly. Make sure dehydration is corrected.
If you have not done any surgery before, or only very little,
If control is not good, start a sliding scale régime of soluble start with the easier operations (Grade 1). You should at least
insulin 6-hrly: be able to open abscesses (6.2). However, in emergency,
Glucose Level Soluble Insulin Needed consider what you can do, and do not be frightened to do it:
0-4 mM 0 IU you may well save lives!
4-8 mM 0 IU N.B. Limited surgery, leaving advanced procedures to an
8-12 mM 4 IU expert, is now accepted practice in damage control (11.3). In
12-16 mM 8 IU emergency, do all you can to save lives: you are not expected
16-20 mM 12 IU to make a perfect repair of everything!
>20 mM 16 IU
Note that in many cultures, operative consent involves the
N.B. It’s best to err on the side of mild hyperglycaemia!
whole family, and not just the individual patient!
If control is by oral hypoglycaemics, omit them on the day
of operation; if the operation is small, they can simply be
Johann Wolfgang von Goethe (1749-1832) in his ‘Maxims
restarted the next day. If the operation is major, convert to a
and Reflections’ wrote: “The most fruitful lesson is the
sliding scale.
conquest of one’s own error. Whoever refuses to admit error
may be a great scholar but he is not a great learner. Whoever
If control is by insulin, reduce the dose in the evening pre-
is ashamed of error will struggle against recognizing and
operatively (if any) by 20%. Administer no insulin on the
admitting it, which means that he struggles against his
day of surgery and set up a 5% Dextrose IV infusion;
greatest inward gain”.
make sure the operation is done early in the day.
Winston Churchill (1874-1965) said, “Success is not final,
failure is not fatal: it is the courage to continue that counts.”

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RULES ABOUT OPERATING: The anaesthetic safety check includes examination of

(1);You must be familiar with the anatomy; if necessary Airway equipment, Breathing system (Oxygen and gases
consult an anatomy book during the operation. available), Suction, Drugs and devices, and Emergency
Do not be embarrassed to do so! medications & equipment, particularly for a difficult airway
(2);You must have someone familiar with anaesthesia giving or aspiration risk, as well as the patient’s fitness. Significant
the anaesthetic. If this is yourself, there must be someone blood loss is >500ml in an adult or >7ml/kg in a child.
else who can monitor its progress and record the patient’s Do not be blasé about how little blood you are likely to lose!
vital signs. You should also have someone available who can Check if you need blood at the start of an operation!
assist during complications, and have airway accessories to The Time Out allows the team a moment to double-check the
hand. Try by all means to get a pulse oximeter to monitor the patient’s identity, and operation.
patient.
(3);There must be a reliable system of sterilization, You can then mention critical steps that you, as the surgeon,
preferably an autoclave. may encounter and so warn the rest of the team.
(4);You must have a good light, preferably adjustable.
A headlamp is useful. The anaesthetist and nurse can do likewise. The checker
(5);You must have the necessary equipment and supplies for should complete Sign Out before you leave the theatre.
resuscitation (infusions, giving sets and cannulae,
a laryngoscope, tracheal tubes, adrenaline, atropine etc) and SIGN IN TIME OUT SIGN OUT
haemostasis (swabs, suction, ligatures, clips). Confirm all OT
(6) Have the highest regard for living tissue and be gentle staff
and circumspect. Operate at your own speed. Use the introduced
technique you know best, not one for which you do not Patient has Surgeon,
actually have the experience. confirmed: Anaesthetist & Verbally confirm:
(7) Remember to give pre-operative antibiotics before you Nurse confirm:
start operating, if indicated. IDENTITY PATIENT PROCEDURE
(8) Finally, do not be too elated over your successes, or too NAME PERFORMED
despondent over your failures. If you do fail, forgive SITE SITE COUNTS
yourself, do not give up! A bad spell during which 2 or 3 CORRECT
patients get complications may be followed by another in PROCEDURE PROCEDURE SPECIMEN
which none of them do. LABELLED
CONSENT
CAUTION! Remember also that with elective operations, Site marked Surgeon review Review of
disasters are more difficult to justify than with emergency of equipment
procedures, both to the hospital staff and to the general critical events failures
public, and that accusations that the doctor is experimenting Anaesthesia Anaesthetic Recovery
on patients can do much harm. safety check review of concerns
done concerns review:
WHO SAFETY CHECKLIST
Pulse oximeter Nurses’ review Nurse, Surgeon
Apart from having the above rules in your theatre,
OK and on of equipment etc. Anaesthetist,
you should use the checklist recommended by WHO.
Allergy: YES/NO
You may have to adapt this according to your local
Difficult airway Antibiotic
conditions. One single person should be responsible for
or Aspiration risk: prophylaxis:
checking verbally with the theatre team each box on the list.
YES/NO YES/NO
The checklist is not something to be done by one individual
Severe blood loss Radiographs
alone, but openly with everyone involved present, much like
risk present:
checking procedures before take-off of an aeroplane.
(blood YES/NO
available?)
There are 3 phases:
(1) Sign In before anaesthesia, YES/NO
(2) Time Out before skin incision, and Make sure you do this for emergency operations as well as
(3) Sign Out before the patient and surgeon leave the elective procedures!
theatre.
(If a box cannot be ticked, leave it blank.) CHECKS AT THE END OF AN OPERATION.
You should be satisfied at the end of a surgical procedure
that you have done everything that needs to be done.
Don’t do things that don’t need to be done:
often complications from those ‘extra’ jobs done will come
back to haunt you!

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Make sure you have: IT IS NOT THE AIM OF SCIENCE TO OPEN

(1) Secured haemostasis A DOOR FOR INFINITE WISDOM,
(2) Washed the operative wound or cavity BUT TO SET A LIMIT TO INFINITE ERROR
(3) Checked any anastomosis Bertold Brecht, in The Life of Galileo, 1939, scene 9, l.74
(4) In the abdomen,
(a) made sure no hernia orifices remain open,
(b) placed the small bowel carefully, 1.9 'Oh, never, never let us doubt what nobody
(c) secured omentum between bowel and skin,
(d) checked a nasogastric or jejunostomy tube is is sure about'
properly in place (if required),
(5) Secured a drain (if needed), Inevitably, these manuals contain a huge quantity of didactic
(6);Made sure the swab, needle & instrument counts are detail with few reasons as to 'why' you should do anything,
correct. and few references to the original papers. We have tried to
select the best methods for your needs. Even so, remember
None of these checks will guarantee that you avoid mistakes, that accepted methods change, that few have been rigorously
but they go a long way to minimize them. Try to establish a evaluated by controlled trials, and that some, which were
‘no blame’ culture amongst your staff, so that when widely accepted only a few years ago have now been
something does go wrong, you can find out what happened, completely abandoned or reversed.
and take corrective measures. Here are some examples of how fallible medical practice can
be:
RULES AFTER OPERATING: (1);Tension sutures used to be used to close a difficult
WRITE THESE RULES UP IN YOUR THEATRE! abdomen, but are now thought to make things worse.
(2);Complete immobilization was and often still is
(1) Ask your staff if you’ve forgotten anything (see above). considered to be the ideal treatment for all long bone
(2) Make sure the patient is nursed semi-recumbent in the fractures. It is now increasingly realized that many of them
recovery position. benefit from early controlled movement.
(3) Check the airway. Suction any secretions. (3);It used to be standard practice to separate mothers from
(4) Make sure there is a post-operative regime of monitoring their babies immediately after birth. Now, this is completely
vital signs, fluid balance, and drugs given. reversed and their close contact immediately after delivery is
(5);Write neat, concise operative notes, preferably with considered essential for bonding.
diagrams: (4);Shaving a patient the day before an operation, which
Name of Operation used to be standard practice, has now been shown to increase
Persons Present the incidence of infection.
Incision
Findings This list could be expanded. So be prepared to ‘doubt what
Procedure nobody is sure about’, even while you follow the didactic
Closure; Drains inserted instructions we give. There is little justification for much of
Time taken what is traditional practice in surgery. There is no
Estimated Blood Loss justification for the ‘arrogance, arbitrariness, stagnation,
Specimens properly labeled & removed imitation, hypocrisy of political correctness, loss of sense of
Postoperative orders reality and resulting pretentiousness one finds among
(6);Make sure nurses looking after the patient understand professionals in the universities, medical schools and
your instructions, especially with regard to IV fluids, drains, departments of surgery.’
Loefler IJP Surgery in the Post-Colonial World (Rahima Dawood Oration).
and pain relief.
E & Centr Afr J Surg 2002;7(1):53-8.
(7);Indicate how to deal with possible problems &
complications. Remember 2 other Winston Churchill aphorisms:
(8);Visit your patient at the end of your operating list, “It is no use saying, ‘We are doing our best.’ You have got
or some time after an emergency case. to succeed in doing what is necessary.”
(9);Encourage breathing exercises and early mobilization: “Criticism may not be agreeable, but it is necessary. It fulfils
this will often go against local culture. the same function as pain in the human body. It calls
(10) Provide good nutrition, skin and oral care. attention to an unhealthy state of things.”
(11) Explain the nature of the operation to the patient.
(12) Organize appropriate follow-up.

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1.10 Creating the surgical machine ALL FOR A PIECE OF CHALK. There was once a professor of surgery
who found to the astonishment that the operating list had been cancelled.
When he asked why his junior assistant replied, "Because there is no chalk
with which to list the cases". The professor was furious and dismissed the
houseman on the spot. The District Medical Superintendent pleaded with
him, “... such a nice boy...”; even the Minister pleaded, but the professor
insisted that he could not have such a person as his junior. So he continued
to clerk his own cases. Finally, weeks later the repentant houseman came to
him and said, "About that chalk, Sir, I think I made a mistake..."
LESSON Failure to improvise, where this is at all possible, is never an
adequate reason for not doing something.

When you arrive inexperienced in a new place, study it

carefully and list the things that need changing.
Then, cautiously and steadily, try to implement them during
the next few months or years. If you do not note them when
you first arrive, you will soon take them all for granted, and
do nothing. Beware of constant change, because the staff
will not accept it. Get to know them and accept their advice
before introducing 'improvements'. Identify keen and active
members of staff, and communicate through them.

Above all, when you operate, start with familiar

Fig. 1-6 WHICH OF THESE SURGEONS ARE YOU? cases at first, and look out early for complications.
Doctor A, found a nearly perfect surgical system and stepped in and out
of it without needing to change it. Doctor B, found a moderately
Do not blame others for your mistakes!
functioning system and slowly let it deteriorate. Doctor C, found a
poorly functioning system and with great effort was able to improve it Then, after 2-3 months, when you have the feel of the place
considerably. Doctor D, found and left chaos. and its problems, visit the nearest hospital where they do
things well, stay a week or two and learn whatever they can
If you are lucky, you will arrive at a hospital where your col- teach you in a short time. Then come back and put what you
leagues and your predecessors have created a smoothly have learnt into practice.
running surgical system. Or, you may arrive and find almost
nothing. More likely, you will arrive and find a system Remember the golden rules:
which is working somehow, and which badly needs 1. Use an aseptic technique.
improvement. 2. Get adequate exposure.
3. Cut under tension and counter-tension.
The presence of pressure sores on the wards will tell you a 4. Ensure adequate haemostasis.
lot, as will the frequency of wound complications after 5. Handle tissues gently.
elective clean procedures. As well as actually treating the 6. Remove devitalized tissue & foreign bodies.
sick you may have to try to make the hospital as a whole, 7. Obliterate any dead space.
and particularly its surgical services, more efficient. 8. Make sure the tissue blood supply is good.
9. Avoid excess tension on any suture line.
To do this you will have to improve: 10. Check the swab & instrument count.
(1) The morale and training of the staff: congratulations are
likely to be much more effective than reprimands. Many problems arise when patients are sedated but not
Explanation of the purpose and value of observations, properly observed: this is one of the most important things
history taking and examination is likely to be more effective you can teach nurses in post-operative care.
than forceful teaching by rote. Use the Ramsay scoring system:
(2) The fittings and equipment.
(3) The administrative arrangements. 1 Anxious, agitated, restless
(4) Your own skills. In doing this you must be prepared to do 2 Cooperative, oriented, and tranquil
any task yourself, no matter how humble and how 3 Sedated but responds to commands
4 Asleep; brisk response to glabellar tap or loud auditory
unfamiliar. There is no place for the attitude, “Oh, but it's not stimulus
my job.” Our jobs, wherever we are, are to create the
'machine' and make it work (1-6). 5 Asleep; sluggish response to light glabellar tap or loud
auditory stimulus
6 Asleep; no response to deep painful stimulus

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The per capita income in the rural areas in many places of

the world where 80% of people live may be <US$50/yr;
the cash income is even lower than that. Estimates as to how
much an Indian villager can spend on health care range from
US36c-$6/yr. It is however less the cost in cash which
devastates the family, than the complete disruption of their
earning power.

Fortunately, the kind of surgery we describe is remarkably

cheap and cost-effective compared with the high technology
surgery of the industrial world. But it is not so cheap in
terms of a villager's income. If you work in a government
hospital, such funds as you have may be provided for you,
but increasingly patients or their relatives have to source the
wherewithal for their own treatment, often on the black
market. The reliability and suitability of such practice is
obviously small, and the opportunity for corruption great.
If you work in a voluntary agency hospital, your patients
probably have to pay, and if you really want to care for them,
you will have to keep your costs low. Complicated methods
can easily lead to rising costs, and so gradually drive the
most needy away.
Instead, your hospital may fill with richer patients,
who could, if they wished, seek care in the towns.
You may become too busy even to notice this! Your high
standing in the community may cause you to befriend the
Fig 1-7 DOCTOR ‘C’ TEACHING THE TEAM.
When Doctor ‘C’ (1-6) arrived he found the obstetric wards in a
elite, and you end up neglecting the poor.
deplorable state, and its beds so overcrowded that rupture of the uterus
occurred in the corridors almost unnoticed. He soon got to work, and PULLING A HOSPITAL 'OUT OF THE RED'
here you see him explaining how to put on gloves. Soon, the obstetric Here is some advice principally from Tumutumu PCEA
services were so efficient that he had empty beds.
Kindly contributed by Holly Quinton
Hospital in Kenya which was able to turn a substantial
deficit in its accounts into a surplus in two years.
It may all be summarized in the words of Denis Burkitt, Try to make the containment of costs, or their reduction, an
the famous African epidemiologist, when asked for an activity which all your staff share. They and you should
autograph on his book: ‘Attitudes are more important than know how much everything costs. If you can make your
ability, motives than methods, character than cleverness and financial decisions by mutual consensus, they will be
perseverance than power, but above all, the heart takes implemented.
precedence over the head’.
Form an action committee consisting of all the spending
departments: the medical superintendent, the administrator,
the matron, and the senior medical assistant. Meet weekly
1.11 The surgical care of the poor and pass all decisions involving money through this meeting.
A good time to start holding such meetings is after some
The purpose of surgery is to heal the sick. What is the use of crisis has occurred, for example, being told to cut your
surgery if the sick cannot afford it? The rapid growth of the budget by 40%. A crisis atmosphere makes people more
populations of many countries requires that we care for ever co-operative, and more willing to change their ways.
more people every year, on a health budget which is not only
low to begin with, but is static, or in some countries is even Examine all funds coming into the hospital and all funds
declining in real terms. going out of it, scrutinize all bills and orders.
Despite this, many patients now know what surgery has to Discuss demands from each department, and reject any
offer, so that their expectations increase steadily. unnecessary ones. Scrutinize all expenditure and expect to
It is deplorable how poor some are. Of the US$2-$6/yr per make some savings on almost everything.
head that is available in many developing countries for all
forms of health care, half or more is spent in the cities, so No single item is decisive, but collectively they make the big
only US$1 a head, or even only a few cents are available in difference. Look at the large items first: salaries, transport,
the rural areas for both hospital and health centre care. drugs and food; even small percentage savings here will
have a big overall effect.

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Rationalize the use of drugs, especially antibiotics. Look at Try to twin your hospital with an institution you know in a
your establishment figures. You may find that your hospital richer part of the world: the benefits of such contacts are not
has got fat and that you should let it get a bit leaner by not just economical!
recruiting after natural staff wastage. You may find that you
have to return to the staffing ratios and technologies (such as Your greatest asset is the pathology arriving at your door:
making your own plaster bandages) of earlier years. use it! Even simple, but carefully carried out, research is
For example, you will probably find that most patients with valuable and will attract funding to your institution from
pneumonia can he treated without a radiograph and so can outside agencies.
most extension fractures of the wrist. Economize with
sutures, IV fluids, lubricant jelly, stationery and so on. Valuable contributions to the surgical care of the poor have
Use IV drugs only when you have to; remember to use the however been made in South America. In Colombia, it was
rectal route (PR) if the oral route is impossible. found that 75% of all the operations were simple enough to
be done on outpatients with a single anaesthetist supervising
Hospital meetings may often be critical. They will ensure the 2 patients simultaneously in the same theatre, mostly using
co-operation of the leaders of all sections of the hospital, local and epidural methods, and adequately supported by
who will transmit the sense of urgency to everyone else. assistants. Operating theatres were only used for 40% of
They will also help to create an awareness of the economic working hours, surgeons only did 120 operations per year
implications of a decision, to establish priorities, and to and 'physicians' only 18.
ensure the continuation and extension of your economy
drive. Follow up your decisions; someone must check that In most hospitals, services are limited less by resources than
the fire is extinguished once the water is hot, or that the right by motivation. So expect to be able to do much more,
weight of the right cabbages has been supplied. even with what little you think you have. The rest of this
Make sure that the staff know how much money is running section shows what can be done, even when resources seem
through their hands, and that the viability of the hospital to be already stretched to their limit. If you think that
depends on how they use dressing materials, gas, and checking the stores is not your responsibility, remember that
equipment. A public chart showing hospital income and it is critically important for the financial viability of the
expenditure monthly will give employees, and potential hospital, on which your whole surgical endeavor depends.
donors, an understanding of your situation.
ECONOMICAL SURGERY
Money coming in is no less important than money going out.
So try to keep your beds full. Work out a policy to reduce STAFF. You may unfortunately have no control here,
costs to the patient, and to make your services affordable to but your influence is great. If possible try to reduce staff to
as many people as you can. Think about what they can pay the bare minimum by not replacing unnecessary personnel,
and be prepared to lower some charges. However, you may and make sure they do a full day's work. Keep existing staff
be able to offer special treatment, for example in a private busy with additional duties. Junior staff are often willing to
ward, to paying patients, especially if they have a medical have more responsible jobs such as filing and typing, or even
insurance. preparing IV fluids.
Such patients may prefer to come to your hospital for more Try to lay off consistently dishonest and inefficient staff.
individual attention than a large teaching hospital in the city. Encourage punctuality, tidiness and cleanliness.
Consider income-generating projects: a restaurant at the Employ inexpensive ungraded staff where you can,
hospital, a vegetable garden, a dairy, a maintenance service, to relieve more expensive staff of routine tasks. Employ
a garage, a hair-dressing saloon etc. multipurpose workers, such as a laboratory technician who
can take radiographs. Employ married couples where both
You may find it financially more reliable and less stressful to partners are gainfully employed. Do not forget training
lease such activities out to a local entrepreneur. Engage your programmes, and encourage success by certificates and
long-stay patients in making handicrafts or using their skills ceremonies. Take advice across the board: anyone may have
for the hospital (e.g. carpentry, electrical work, sewing). a good idea! This is a strong motivator for staff as they feel
Persuade the major players in the community to invest in the involved.
hospital, e.g. the bank or post office; a branch at the hospital
will be very popular with staff and a big time saver. SAVINGS ON CONSUMABLE MATERIALS
This requires marketing and data collection: make a survey Dressings. If necessary, you can treat most wounds without
of local demands, and needs. One hospital in India had dressings. Clean closed surgical wounds do not need them.
considerable success producing CD’s of elective operations Use gauze and cotton wool economically. Do not make
and selling them to the patients concerned! dressings larger than is necessary. Re-sterilize all dressings
which have not been soiled.

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Avoid using strapping, but if you do use it, use narrow strips Use nylon syringes, such as the French KIGLISS pattern,
and do not allow it to be used anywhere except on the human which you can sterilize indefinitely, and which have a rubber
body. ring to seal the plunger which you can purchase separately.

Hold dressings on with bandages, socks, caps, bras, Do not use disposable urine bags; instead, use bottles and
tight vests, pants etc. tubing from old intravenous sets. Re-use endotracheal tubes
after thorough washing and cleaning with ‘Cidex’ (2.5).
Wash gauze sponges, immerse them in water to remove
stains, dry them and re-sterilize them. If necessary cut up an Catheters. Use simple Jacques catheters if they are less
old polyurethane foam mattress or cushion into small squares expensive than Foley catheters; if you want to leave them in
and use these as swabs and sponges. They absorb blood well. situ, secure them with strapping. Consider carefully if the
Cut up and sterilize old linen. Sterile toilet paper can be used catheter is necessary anyway.
as an alternative to swabs for some purposes.
IV fluids. Make your own for 7% of the price of the
Make up laparotomy pads. Use a sewing machine to join commercial ones. Where possible, use rectal rather than IV
enough pieces of gauze 20x25cm together to make a 5mm fluids. These are not suitable for rehydrating patients,
layer; attach a tape to one end, and when you operate attach but they may be adequate for maintenance. If IV fluids are
a large haemostat to the tape and leave this hanging out of scarce for postoperative patients who have had major
the wound. Laparotomy pads are a more convenient and gastrointesinal or other surgery, insert a nasogastric tube for
economical way of washing and reusing gauze than using it drainage and a naso-jejunal tube for feeding. In this way you
as swabs, and can replace them for some purposes. will greatly reduce your need for IV fluid.

Keep an open wound wet with water. Keeping a wound dry Oxygen is only necessary for such indications as pulmonary
uses many more dressings than treating it wet. The water oedema, asthma, shock, or coma, but not for moribund
need not be sterile, and need not contain salt (except where patients. If you use it for patients with no hope of survival,
sodium loss is important as in burns). Use large quantities of relatives may come to believe that when you switch it off,
water: soak, wash, shower or spray the wounds! it killed them! Get hold of oxygen concentrators:
the economy is well worth the initial expense.
If a wound is suitably sited to be immersed, as with the
arm, leg, or buttocks, immerse it in water for 3hrs bd. Drugs. Use cheaper drugs instead of expensive ones.
Put a leg in a bucket, an arm in a long arm bath, and let a For curettage of the uterus use pethidine with diazepam
patient with a buttock wound sit in a hip bath. instead of ketamine; use aminophylline instead of
salbutamol, aspirin instead of paracetamol, nitrofurantoin
If a wound is not suitably sited for immersion, keep it wet instead of ampicillin for urinary tract infections, and
all day. morphine instead of pethidine for many applications.
N.B. dressings in these situations only serve to protect the Look carefully at the prices you pay for drugs. One supplier
environment. may be 100 times cheaper than another, but beware
counterfeit products! Always consider if antibiotics are
Disinfectants. Do not fill gallipots to the brim. really necessary: they are often over-used! Do not practice
Use cotton wool, not gauze for scrubbing the skin. poly-pharmacy!
Do not use disinfectant for the preliminary 'scrub' to remove
dirt; use soap and water. One gallipot of disinfectant will Sutures. Where possible, use surgical suture material bought
then be enough to prepare the skin. You can use it all day: in bulk on reels, or use nylon fishing line (4.6).
it is self-sterilizing. Only use atraumatic sutures when they are absolutely
necessary. With more expensive suture materials, use
Disposable items. Avoid these and replace them by continuous sutures rather than interrupted ones.
permanent equipment. If you buy plastic equipment which is The application of warm moist gauze packs (especially if
intended to be thrown away, choose the kind which you can soaked in dilute adrenaline) to a bleeding surface will
autoclave or boil. Recycle everything you possibly can, drastically reduce the number of bleeding vessels that you
and try to throw nothing away. need to tie. Use sewing cotton for simple ligatures.
Buy the kind of gloves you can re-sterilize 3-4 times.
Re-use clean sterile gloves as disposable gloves. Scrubbing up. Use ordinary soap not special fluids, if the
Re-use clean disposable gloves for general cleaning work. first costs less.

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SAVING KITCHEN SUPPLIES Solar lighting is practical, virtually maintenance and cost
Find the cheapest supplier and buy at the right season. free and its initial installation is becoming less expensive.
Find out if buying in the market may be better. Solar heating, by allowing the sun to warm black pipes is
Watch tenders carefully, change suppliers when necessary, very effective for producing hot water.
and insist on good quality. Do not let them supply you with Solar refrigerators are available, but their initial cost is high.
old, rotten, or small potatoes. Buy boneless meat, especially Invest in invertors to convert solar 12v to 240v, but beware
offal (liver or heart). Adjust the number of meals cooked to that you do not overuse your batteries. Use solar or hand-
the bed state. Provide high protein diets only on genuine cranked batteries.
indications. Reduce waste. Fill plates moderately and vary
helpings according to the appetites of both patients and staff. OTHER SAVINGS
Keep your own livestock to feed on waste and run your own
vegetable garden if possible. Use the space fully on all case sheets, use paper on both
sides. Make your own forms with a stencil. Minimize the use
ENERGY SAVINGS of paper for internal correspondence. Use scrap paper for
messages.
Washing. Use the timers to set minimum times for washing Do not use so much detergent that it causes foaming in the
and spin drying carefully. Avoid tumble dryers unless the laundry and when scrubbing floors.
climate is very wet; they use much electricity. Register and charge for private phone calls. Send letters with
your hospital transport if possible. Use e-mail or electronic
Petrol or diesel. Diesel vehicles may be cheaper to run but messaging if you can.
need more careful maintenance. Use the smallest economical
vehicle for a given job and avoid unnecessary trips. Control all items that could be used in private homes,
Keep logbooks and use vehicles for hospital journeys only. including torch batteries, soap, matches, pens, toilet paper,
Drive at economical speeds and use moderate engine female sanitary pads, food and medicines. Be firm on
revolutions in all gears. Use public transport wherever discipline when it comes to theft. Remember theft probably
possible. Encourage a style of driving that is considerate for accounts for your greatest ‘expenditure’: inventories and
the vehicle, especially when carrying heavy loads on bad security are mandatory. Proper accounting systems are also
roads. essential: otherwise money will just ‘disappear’!
Also, do not delegate ordering of stock or equipment to a
Gas. Put lids on pots. Reduce the flames when the pot has junior; not only will you get the wrong things but you will be
boiled. Use pressure cookers. Control cooking times. conned into buying expensive varieties of cheap things.
You may be able to insert a system that utilizes gas from Beware offers of ‘new’ equipment from unknown dealers:
compost or sewage, which is very cost-effective, although it is probably stolen or cheaply repaired and will not last.
expensive to install. Practice regular maintenance. Keep an eye open for
breakages and organize repairs early. Establish a climate of
Electricity. Switch off lights when unnecessary (e.g. in accountability. Remember to order stock with sufficient time
daylight!) Use fluorescent tubes instead of bulbs. Heating is to allow for delivery and delays: do not wait till the last Xray
much more expensive than lighting, so make sure it is used film is in the hospital before ordering new supplies!
where really necessary. Make sure you have universal Otherwise you will be forced to improvise with expensive
connectors so you don’t waste time and expense on adaptors. items because the cheaper ones have run out (e.g. using
LED lights (e.g. on a headband) are extremely effective and 3-way catheters when ordinary ones are actually needed).
use minimal power, so are useful if you have to rely on
Solar energy.

Air Conditioning. In hot humid climates, a cool air 1.12 Primary care imaging
environment makes life and work much more comfortable.
Electrically driven air conditioners are expensive and Radiology uses X-rays which provide much useful
frequently break down, and heat up surrounding areas information, particularly about bones but ultrasound (38.2)
outside the room they are cooling down! If you insert a can replace radiographs for very many indications, especially
system of PVC pipes 3m below ground, where the earth in obstetrics except for X-ray pelvimetry. Think carefully if a
temperature is virtually constant, and blow air through these radiograph is likely to give you essential information.
pipes with a simple fan, you can cool the room temperature Remember quite sophisticated interventional radiographs can
by about 10ºC and reduce humidity by 40%. be taken with simple means (38.1).
This system also avoids the dust that regularly contaminates
electrical air-conditioners. THE PATIENTS ARE OURSELVES

21
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Ultrasound is an extremely useful modality, and you should

really not be without this useful tool. Ideally, it should be
portable, and must be suitable for obstetric evaluations.
You do not need many types of probes, but it is almost
essential to have a trolley where the probes can be safely
placed so they are not damaged. You certainly do not need
the extra gadgetry (freeze control) needed for taking still
pictures, or on-screen measurements (though this is
helpful).In fact, the fewer the knobs the better and more
consistent are the images you will obtain.
A computer attached and key console are not essential.
The more features the system has, the less transportable it
will be. If you intend to take it to distant clinics, make sure
it is robust, and comes with a specially padded case.
Make sure it runs on rechargeable batteries.

TALE OF FOUR PEOPLE, Everybody, Somebody, Anybody, and Nobody;

There was an important job to be done and Everybody agreed that it could
be done by Anybody. It was agreed that Somebody should be detailed off to
do it, but although Anybody could have done it, it eventually got done by
Nobody. Somebody got angry about it, after all (he said) it was Everybody's
job. But, while Everybody thought that Anybody could do it, Nobody
realized that Everybody was going to assume that Somcbody was going to
do it. It ended up that Everybody blamed Somebody when Nobody did what
Anybody could have done.
LESSON. This book is written to benefit Everybody, so that Anybody who
is put in charge of surgical patients will know that Somebody cares enough
to write down methods of surgery in a way that a 'Nobody' can find that he
or she can do Something even if tucked away in the middle of Nowhere'

Fig. 1-8 THE BRS X-RAY SYSTEM was developed by WHO to make
essential cost-effective radiology available safely and reliably all over 1.13 How to use these manuals
the world. If you want one of these machines, order one made to WHO
specifications. Note the screen protecting the operator.
Kindly contributed by Philip Palmer.
You will notice that after 5 chapters on 'the basics' there are
WHO has made a great advance in the X-ray departments of the world's
district hospitals by developing the BRS (Basic Radiological System).
5 on draining pus. Then come chapters on the abdomen and
The BRS machine shown (1-8) is made by several manufacturers to WHO hernias, followed by obstetrics, gynaecology, and the breast.
specifications. If you are thinking of buying an X-ray machine, this is the After this there is the surgery of special areas (thyroid,
one to get. If you do not have electricity all day, you can run it on a battery proctology, urology, etc.) then finally terminal care and
which you charge when you turn your generator on. It is so simple that a
radiographic assistant can easily work it, but if you have a radiographer who
imaging.
has been trained to use a more sophisticated machine, he may not like this
one because it does not give him enough freedom to adjust the settings. After dealing with general principles of trauma management,
The BRS machine is based on the assumptions that: (1) A good chest Volume 2 deals with various regions in turn.
radiograph needs a short exposure, and a substantial distance between the
patient and the tube. (2) A radiograph of the lumbar spine will be one of the
heavier exposures required. It has therefore been designed to produce at In writing these manuals we have tried to make both
least 80mA at 18kV, not one or the other, but both simultaneously. It has a language and the typography work for you. You will notice
fixed tube-to-film distance of 140cm, which gives satisfactory chest films that we use the imperative, avoid the passive voice, and refer
and is the ideal distance for most other investigations. The tube is fixed so
that it can use an accurately focused grid of high quality. The tube and the
to ‘the patient’ and then mostly to ‘him’, which does in fact
film are always accurately focused on one another and cannot be angled usually mean both ‘him and her’. Alas, English, unlike
independently. This makes it easy to position the patient and makes routine French, has no personal pronoun which includes both sexes
views exactly repeatable. The supporting arm of the tube and the film can be and we have refused to use the grammatically incorrect
rotated through at least 270º, so that horizontal and vertical projections are
easy, and angled views are possible. Erect views of the skull, sinuses,
‘them’. Our use of ‘he’ or ‘him’ to include both sexes
shoulders, or abdomen are as easy as routine views of the chest. improves clarity, and shortens the text, but we owe our
A radiographer's manual is available; so is a manual of radiography to go apologies to our lady readers!
with the machine. We have used 7 degrees of approximate commonness:
very common, common, not uncommon, uncommon,
ECONOMY IS ESSENTIAL TO SURGERY unusual, rare and very rare. This is based on experience of
the authors and may not apply exactly in your situation.

22
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Inevitably, we are mostly concerned with technology but

behind all this lies the patient himself. The boy with the
fractured radius and ulna waiting at the end of the queue
might be your own son, that paraplegic your brother, that old
lady with the fractured femur your mother. Tomorrow,
we might ourselves be that comatose patient with the
extradural haematoma in the end bed. These patients are
ourselves! Perhaps the thing that we most often miss is any
explanation of what is going to happen to us, and any
indication that anyone really cares. Believing the
compassionate and devoted care of the sick to be one of the
noblest human activities, and something of ultimate value for
its own sake, we stress this!

We trust that this volume will enormously improve medical

care as it did in St Francis Hospital, Ifakara, Tanzania.
This showed that these manuals had been put to good use.
They contain much detailed factual information, and we
have done our best to make them as easily understandable as
we can. Feel free to disseminate this knowledge as you see
fit: we make no restrictions on your keenness to photocopy
the text.
If, however, you would like to translate the text into your
own language, please contact the Editors who will be happy
to hear from you!
Fig. 1-9 YOU MAY HAVE SIMULTANEOUSLY TO BE SURGEON
Take this book to the wards, clinics, and operating theatre. AND ANAESTHETIST.
Kindly contributed by de Glanville N. Proc Assoc Surg E Afr.
How does the treatment you see given differ from that
N.B. This cartoon is no longer very up-to-date: now you are much more
described here? The methods of examination we give are likely to use ketamine than inhalational anaesthesia; also we recommend
summaries only, practice them on a fellow student. that you train a nurse or clinical assistant to monitor the patient during
the operation, to warn you if there is a problem.
We are all students, and should never give up learning new
things. Do not be overwhelmed by the mass of detail you find Certain drugs have been re-named in English usage
here. Do not panic, and do not think you need to read cover according to European regulations; whilst generations of
to cover! These pages differ enormously in importance. readers will probably still use and write the old names, the
Try to distinguish between what you should know, and what new ones are given for correctness. Nonetheless, you should
you can look up. liaise with your pharmacy as to your own local usage!
It goes without saying that prescriptions MUST be legible.
You will notice that much of the writing is didactic.
This guidebook is a distillation of the cumulated experience New Name Old Name
of very many dedicated surgeons and physicians working in
challenging environments. Also, there are very few Amoxicillin Amoxycillin
references, because adding these would have hugely Cefalosporins (all types) Cephalosporins
increased the volume of the text, and they cannot readily be Chlorphenamine Chlorpheniramine
looked up by our readership. Many references are old, but Diethylstilbestrol Stilboestrol
are still very relevant in low-income situations, again Furosemide Frusemide
reflecting how advances made in the rich world are often not Indometacin Indomethacin
translatable to the poor world. Levothyroxine L-Thyroxine
Lidocaine Lignocaine
If, however, you find something really does not work in your Procain Benzylpenicillin Procaine Penicillin
set-up or you have good practical suggestions please write
and let us know.

23
 24

A SUGGESTED INITIAL READING LIST Do not let things you cannot do, because you do not have the
Start by reading the whole of this chapter. In those which necessary equipment or drugs, prevent you from doing the
follow, read only the introductory passages, and merely things you can do.
glance at the detailed didactic instructions which follow.
Whenever you refer a patient, try to learn from the person
Read these carefully later when you need them to guide you you refer him to. If possible, be there when he is examined.
in a specific situation. Start with the common things first. In the same way, if someone refers a patient to you,
he should be there so that you can teach him.
Read particularly the first section of each chapter and the
following: the major theatre (2.1), aseptic theatre technique What methods are your staff using? For example, if medical
(2.3), autoclaving (2.4), antibiotics in surgery (2.7 to 9), assistants treat fractures in your hospital, study the methods
the control of bleeding (3.1,2), bloodless limb operations they use and encourage them to use those described here.
(3.4), the instruments (4.1-5), suture materials, sutures and If they might find this manual useful, see that they have a
needles (4.6 to 8), drains (4.9), instrument sets (4.12), copy and go through it with them.
'pus' (6.1 to 24), pyomyositis (7.1), osteomyelitis (7.3),
septic arthritis, especially the positions of rest and function If a patient dies and you are not sure of the diagnosis,
(7.16), hand infections (8.1), empyemas (9.1), try to get permission for a post-mortem examination.
peritonitis (10.1), abdominal surgery (11.1 to 15), the acute
abdomen and intestinal obstruction (12.1 to 16), Make good use of the endpapers and charts you find in these
appendicitis, (14.1), inguinal and femoral hernias (18.1 to 8), manuals:
and PID (23.1). WHO Safety Check List (1.8), Endoscopy form (13-10),
Partogram (21-2), Fundal height chart (22-15), Baby head
THE MAIN ANATOMICAL DRAWINGS are the circumference chart (33-17), & Foetal growth centiles
following: mandibular region (6-7), parotid (6-8), (38-6,7,8).
mouth (6-9), anorectum (6-13, 26-1), anterior thigh (7-18), Where convenient, photocopy them and stick them up on the
hand tendon sheaths(8-4,7), pleurae (9-1), peritoneal cavity wall, or have them printed.
(10-5), anterior abdominal wall (11-1), broncho-pulmonary
segments (11-23), biliary tract (15-3), inguinal region IF YOU ARE A SURGICAL TEACHER, try to integrate
(18-3,4), uterine blood vessels (22-14, 35-20), relations of these manuals into your teaching, and base your examination
the ureter (23-20), ligaments of the pelvis (23-21), questions on them. Aim, less that the students should know
eye (28-1), auditory pathways (29-2), carotid artery (29-7), these manuals, than that they should know their way around
tonsil (29-10), tibialis posterior (32-29), ventricular system them, and be prepared to use them.
(33-18).
There are also the following transverse sections: In-patient hospital records often provide life-saving
forearm (7-8), thigh (7-9, 35-18), calf (7-11), hand (8-1), information which cannot be found elsewhere; they are a
ankle (32-18), wrist (32-35). medico-legal obligation, and should contain all the important
details of patients. There is no real need for nurses and
IF YOU ARE A GENERAL DUTY MEDICAL OFFICER, doctors to keep separate records. Both could write in the
do not be ashamed to refer to these manuals. A patient will same set of notes! A proper hospital filing system is
be more grateful for being correctly treated than for being essential; notes are best stored by number (not name,
wrongly treated because you could not remember something as patients may use different names on occasions) using the
and had to guess! For example, you cannot possibly last two digits, thus:
remember all the steps in the general method for a spinal
injury, or a hand injury, so why not refer to them in front of a ……236000, 237000, 238000….259100, 269100,
patient until you have examined so many patients that the 278100….243200, 252200, 255200….etc…..209800,
necessary clinical routines become automatic? 243800, 246800etc…..256001, 264001, 265001….201002,
If his condition is difficult to diagnose, ask him to wait until 222002, 265002….etc
the end of the clinic, and then use the routines we give here
to try to reach a diagnosis. A patient’s ID number could be used if necessary.

Keep these manuals in the theatre. If a procedure is long or Patients’ social details should indicate: Name, Date of Birth,
difficult, sit in an armchair and study it in peace, before you Address, Next-of-kin, and mobile phone number.
try to do it. Then study it again after you have done it.
Do not expect to be able to do everything we describe If you can get your hospital records digitalized, so much the
immediately. Progressively extend your practice, little by better, but remember that your hospital ‘memory’ will need
little. constantly to be upgraded!

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 25

MEDICAL NOTES should be accurate, legible and

comprehensible. There should be an admission note
(with history and physical findings), continuation notes
(with results of relevant investigations) commenting on
progress and giving instructions, and finally a discharge
note.

It is good practice to provide patients with their own

out-patient cards: brief notes are made on clinic visits,
and in-patient summaries are included:

(1) Hospital Number

(2) Date of Admission,
(3) Diagnosis with relevant signs,
(4) Operation done,
(5) Complications,
(6) Lab results (especially histology),
(7) Date of Discharge & Review.

Never ever be tempted to alter the notes of a patient.

You may, however, add a comment later (with a date) if you
feel it appropriate.

IF YOU ARE A STUDENT, LEARN THE

IMPORTANT THINGS FIRST

Fig. 1-10 A PATIENT’S RECORDS, as kept by Peter Bewes (adapted).

Good notes are an excellent indication of quality of care. You may like
to indicate the reasons for admission and orders: in this case, “Prepare
for Gastrojejunostomy. Check Hb. Rehydrate IV N/Saline 1lit 3hrly with 1
ampoule KCl with each lit. Pass NG tube. Check clotting time. Give Vit K
10mg IM. Discuss with relatives”.

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2 The surgical Two zones in the theatre ensure this:

(1);A sterile zone which includes the operation site,
the first 3 members of the team, and that part of the theatre
infrastructure immediately around them.
(2);An unsterile zone which usually includes the head end
''It is one thing to operate with the chief at your elbow on a patient whose
vital functions are being monitored by an expert anaesthetist at the head of the patient, separated from the surgeon by a towel rest
of the table. It is quite another to be almost alone at midnight, struggling and the remainder of the theatre. The last 3 members of the
with a patient in shock from a ruptured ectopic pregnancy, as the light team can move freely within this zone. The patient's
fades in and out while a superannuated generator tries to function on entrance and the access to the sluice room are continuous
adulterated diesel oil. Then is the moment of truth when you realize that
an excellent theoretical foundation is not the only thing you need.” with it. A separate room for scrubbing up is not essential;
Hankins GW, The former Shanta Bhawan Hospital, Kathmandu, Nepal, scrubbing is possible in the theatre in two domestic pattern
Annals Roy Coll Surg Engl 1980; 62(6):439-44 sinks with draining boards. They should be fitted with
elbow taps which are very highly desirable, although you
can, if necessary, scrub up from a bucket or use
2.1 The major theatre spirit-based cleansing solutions. The boiler, autoclave,
preparation room, and store rooms should be outside the
Although aseptic surgery has been done in a tent, theatre.
under a tree, or on a kitchen table, it is safer if it is done in
a room which has been designed to preserve the sterility of
the surgical field, to make surgical routines easier,
and to prevent mistakes. The difficulty with aseptic
methods is that they require an autoclave. If you do not
have one, we describe an antiseptic method that you can
use instead (2.6).
Do all you can to prevent nosocomial infections, i.e. those
reaching the patient whilst he is in hospital. Such infection
may come from himself, other staff, equipment and
instruments, linen, furniture, floors, walls, water, toilets
and insects. Things that come in contact with sterile
internal parts of a patient need sterilization (2.4) whilst
those that come in contact with intact mucous membrane
need disinfecting (2.5). Other items need simple cleaning.
You will need 2 theatres at least; a major one and a minor
septic one (2.2). We are concerned here with the major
one. When you start work in a theatre, look at it carefully.
How many of the desirable features that we are about to
describe does it have? Is there anything which you could
do to make it safer or more efficient?
The operating team should be as small as possible. Fig. 2-1 STERILE AND UNSTERILE ZONES IN A THEATRE.
It consists of: A,sterile zone (white) in a vertical dimension. B, sterile zone in a
(1) Yourself, the surgeon. horizontal dimension. The sterile zone contains the operation site,
the instrument trolley and the three scrubbed up members of the
(2) Your assistant(s), when you need one or two. surgical team. The unsterile zone comprises everything else in the
(3) The scrub nurse responsible for the instruments. theatre. The sterile zone is separated from the unsterile zone by a
(4) The circulating nurse to fetch and carry. towel rest. The great danger, when technique is poor, is for the sterile
(5) The anaesthetist. zone to become smaller and smaller as the operation progresses.
(6) His assistant, if he has one.
Adequate space is essential, so that staff can move freely
Two other people are important:
within their zones, and without touching one another.
(a) The theatre charge nurse responsible for organizing
Space is needed for manoeuvring and parking the patient's
the theatre, and who in a smaller hospital will usually take
stretcher next the operating table, and for parking trolleys
turns being on call,
without congestion. The absolute minimum is 25m2;
(b) the 'theatre assistant’ who, unlike the nurses who
a room 5x6·5m (32 m2) is better, and 42m2 is ideal.
come and go, may have spent his whole career in the
The more equipment you have in the theatre, the more
theatre and in that case will know its routines and where
space you need, and in ideal conditions 64m2 is normal.
things are.
If the case load is heavy, a 2nd theatre is more useful than
In an emergency, rôles (2) & (3) can be combined in an
making the 1st one unduly large, unless you plan to run
efficient nurse or medical assistant, and so can roles
2 operating tables in the same theatre; this is useful
(4) & (6). The first 3 members of the team are clothed in
if you have only one anaesthetist to supervise cases.
sterile gowns, the last three are not. An important part of
A large operating theatre with areas not used will not be
the drill in theatre is to prevent the last 3 from
properly cleaned.
contaminating the surgical field and the first 3.

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Straightforward physical cleanliness is important. Do not have more shelves than you need, but keep the
Sophisticated methods are unnecessary. Sluicing the floor things you need daily nearby; use trolleys where you can.
between cases, washing the walls weekly and When shelves are needed, set them 50mm away from the
mobile equipment daily will ensure a high enough wall on metal rods, so that they can be lifted away for ease
standard without using antiseptics on the theatre itself. of cleaning. All shelves should be at least 1m high so that
The floor is important. trolleys can be pushed under them. The glove shelf should
The most dangerous sources of infection are pus and be at least 1·2m high, so that you can keep your hands
excreta from the patients, which must be cleared away higher than your elbows to prevent water running back
between every operation, and must not be allowed to down over your now dry hands. The anaesthetist needs a
contaminate the theatre. To make this easier, it should lockable cupboard, a trolley, a worktop near the patient's
have a terrazzo floor, but a smooth concrete finish is head.
almost as good and much cheaper. To make it easier to
wash down, it should have a 1:1000 slope towards an open Electric sockets should be 1·5m above the floor to
channel along the foot of the wall at the unsterile end of minimize the danger of igniting explosive gases,
the theatre. This channel should have a plugged outlet and damage from moving beds and trolleys. Make sure
leading directly outside to an open gulley. Fit a sparge pipe your electric sockets are uniform, and you have equipment
to the wall at the sterile end 150mm above the floor, working with the hospital voltage. You can easily overload
so that the whole floor can be flooded by turning a tap. the system if you have lights, a sterilizer, suction
A little dust on trolley wheels or shoes, or from open machines, lights, fans, diathermy all working at the same
windows, is less dangerous than is generally believed, time. Make sure you have an emergency power source.
but remember hair, fibres and fluff tends to get caught in A foot suction pump, and hand-torches are useful in a
wheels and need to be periodically removed. crisis.
The walls of the theatre should be smooth, but they need
not be tiled. A sand and cement backwash application Basic requirements are:
painted with one coat of emulsion and two coats of
OPERATING TABLE, simple pattern. The minimum requirements of an
eggshell gloss is adequate. Gloss paint is satisfactory for
operating table are that: (1) you must be able to tilt the patient's head
the walls, and the fewer the doors, sills, ledges, crevices, down rapidly for the Trendelenburg position, and if he vomits.
mouldings, architraves, and window boards, the better. (2) you should be able to adjust its height. This table does these things at
The main point is that the walls must be washable a fraction of the cost of the standard hydraulic ones, which need careful
maintenance, and are useless when their hydraulic seals perish.
preferably up to 3m.
However, if a simple general purpose hydraulic table is well maintained,
Every time a door is opened, dust from the floor is whirled it lasts a long time. A really sophisticated one can cost as much as the
into the room. There is no need for a door between the entire building of the theatre. A dirty table is a menace, so make sure
changing rooms and the theatre. A door is only needed yours is kept clean.
If the head of your table does not tilt head down, get one that does.
between the sluice and sterilizing room, if these rooms will
Meanwhile, in an emergency, you can put a low stool under the bar at its
be used when the theatre is not. foot. If it does not tilt from side to side, make a wooden wedge to fit
under the mattress. If it does not have a kidney bridge and you need one,
The ceiling should be at least 3.5m high and the roof use folded plastic covered pillows.
Locally made 'Chogoria' supports (19-3) are a useful addition to a
timbers solid enough to support an operating light.
standard table. They are made of 2 suitably bent pieces of pipe which fit
It should also have a pair of 2m fluorescent tubes, into the holes for ordinary stirrups and keep the patient's hips widely
or LED lights. abducted, and the hips and knees moderately flexed, so that the lower
The ambient level of illumination should be high, so make legs are horizontal. The legs rest on boards attached to these pipes.
These supports are more comfortable than stirrups and are particularly
the windows big enough. They may enable most
useful for such operations as tubal ligation.
operations to be done by daylight. A suitably placed ALTERNATIVE OPERATING TABLE, Seward minor or equivalent.
mobile mirror to catch the bright sunlight is very useful. This is slightly more versatile and considerably more expensive than the
There should be a window of 5m2 at the head and the foot table above.
MATTRESS, for operating table, with three or more mackintosh covers.
ends, facing north and south shaded by a roof overhang of
A dirty mattress is a potentially serious source of infection. So swab the
at least 800mm. Even better are windows on three sides. cover after each patient, and replace it regularly.
Fit ordinary low windows, and frost only the panes below ARM BOARDS (2), for operating table, locally made. These are simply
eye level, so that the staff can look out (which improves pieces of hardwood about 20x120x1000mm, which you push under the
mattress to rest the patient's arm.
morale), but that anyone looking in can only see their
STOOLS (2), operating, adjustable for height, local manufacture.
heads, not the patient. If you do much operating, a chair with a padded seat, wheels, and a back
greatly reduces fatigue.
In the tropics avoid windows in the roof. You may need LIGHT, operating theatre, simple pattern, preferably with sockets to take
bayonet or screw fitting domestic pattern light bulbs, in addition to
fans to reduce the temperature, but remember they can
special bulbs. Most operating theatre lights take bulbs which are
blow dirt and dust into wounds! Electrical air conditioning irreplaceable locally, and may cost US$70 each, so find out what bulbs
is notorious for collecting dust and transmitting bacteria: your light takes, and try to keep at least three spares. Record their
it should not be a high priority: use an alternative (1.11). specification and catalogue number somewhere on the lamp casing.
When new lights are ordered, they should have fittings that can,
Make sure the theatre still remains warm enough:
if necessary, take ordinary domestic bulbs. An LED operating or head
hypothermia due to exposure still occurs in tropical light is a very useful help or alternative.
regions, especially at night. It is comfort of the patient,
who is practically naked, not of the surgeon, that is
important.

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The preparation room should lead off the theatre.

A big one is desirable, because it needs to contain
2 autoclaves, a large and a small sterilizer, sterile packs,
instrument cupboards and space to lay out instrument
trolleys. Ideally, it should be 64m2 and serve 2 theatres.
About 25m2 is the absolute minimum, with a terrazzo shelf
round most of two walls, a sink, a draining board, a single
vertical autoclave (preferably two), a large boiling water
sterilizer standing on the floor, and a small one on the
bench.

Fig. 2-3 IMPROVISED LIGHTING.

A, If you have to make a light locally, suspend 4 car headlights on a
cross, and suspend each end of it on a pulley counterbalanced with a
weight. B, better, put the counterweights in a metal casing which will
be easier to keep clean. Or, less satisfactorily, hang three fluorescent
tubes from the ceiling in the form of a triangle. This is basic but
significantly better than nothing!

CLOCK, wall, electric, with second hand. This is essential, you must
have a proper awareness of time, especially when you apply a tourniquet
(3-6), and without a clock you can readily forget it. The instructions
given here for controlling bleeding by applying pressure sometimes tell
you to wait 5mins by the clock.
INSTRUMENT CABINET glass door, sides and shelves,
1300x600x400mm, local manufacture.
RADIOGRAPH VIEWING BOX, standard pattern, local manufacture.
INSTRUMENT TROLLEYS (4) without guard rail, with two stainless
steel shelves, antistatic rubber castors, (a) 600x450mm, and
(b) 900x450mm. Glass shelves ultimately break, so stainless steel ones
are better. A larger table will make it easier to lay up for larger cases,
especially orthopaedic ones.
STAND, solution, with antistatic rubber-tyred castors, complete with two
350mm stainless steel bowls, side by side. Put water in one bowl, and use
the other for spare instruments and the sucker. The bowls can be
sterilized in the autoclave or in a boiling water sterilizer.
DRIP STANDS, telescopic. Or, less satisfactorily, use long wire hooks
suspended from the ceiling near the head of the table. Hooks for drips
sticking out from the wall are useful above some beds in the wards.
SUCTION PUMP, operating theatre, electric with two 1lunbreakable
plastic bottles and tubing. These are always breaking down, so the model
Fig. 2-2 A SIMPLE THEATRE AND ITS TABLE. chosen must be easy to service and spares should be available.
A, this is about the smallest practical theatre possible. B, simple If you are going to depend on an electric sucker, make sure it can actually
pattern operating table described. suck before the operation starts. A sucker which makes a noise may not
A, adapted from Mein P, Jorgensen T, Design from Medical Building, necessarily suck.
AMREF, Nairobi, 1975 with kind permission SUCTION PUMP, foot operated, with two wide mouthed 1lunbreakable
plastic bottles, rubber bungs and metal tubes.
SPOTLIGHTS (2), free standing on the floor, 'Anglepoise' type, to take This is an automobile pump with the valves in it arranged to suck instead
ordinary domestic pattern bulbs. Also, high efficiency internally of pumping. Both the surgeon and the anaesthetist need a sucker,
reflecting bulbs (5) to give a parallel beam. These are necessary, so you need 2 at least. A hospital workshop may be able to make one of
both as a standby to the main theatre lamp, and to illuminate positions these suckers by altering the valves of a truck tyre pump.
that the main theatre light cannot reach. A normal spotlight can direct an A foot sucker is much more reliable and more easily repaired than an
undesirable amount of heat into the wound, so, if possible, get LED lights electric one. If you use an electric sucker, make sure you have a foot
which produce little heat. These are more expensive initially, but have a sucker also.
longer life. You can improvise a spotlight by removing the headlight of a SUCTION TUBES, metal, Poole’s abdominal, wide bore, with guard.
car, especially the sealed beam type, and attaching it to a drip stand in the The standard laryngeal suction, the Yankauer type, is used by the
theatre. Connect it with a long lead to the battery of a car outside. anaesthetist at almost every operation, but not so useful for the surgeon.
Or use a slide projector held by an assistant. If the level of illumination is A small Gilles suction tube is useful for fine operations.
not enough, especially for eye surgery, you can increase the contrast by Connect it through a piece of sterilized rubber tube to one of the suction
blacking out the theatre. pumps.
SOLAR PANEL, charger, and battery. A single solar panel will collect a (If you do not have a suction tube, suck using the rubber end on its own,
useful quantity of electricity and enable you to light two wards in the but beware of damaging bowel if the suction pressure is high.)
evenings. DIATHERMY. Bipolar diathermy is only useful for fine surgery;
BATTERY CHARGER for the common sizes of rechargeable dry otherwise a simple unipolar diathermy is sufficient.
batteries, and five rechargeable batteries of each size. This will enable
you to recharge batteries for your torches and laryngoscopes etc.

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MONITORING EQUIPMENT. A pulse oximeter is very useful; GOGGLES, wrap-around, industrial. These should be used when drilling
a continuous ECG monitor is valuable but less essential. Expensive or splashes are expected.
continuous blood pressure recording equipment is desirable but GOWNS, cotton. These should go right round the wearer and cover the
unnecessary, and if faulty may give a false sense of security. back. They should have long enough sleeves to reach the surgeon’s
SUITS, theatre, cotton, with short sleeved shirt, and long trousers, wrists. Before sterilisation they must always be folded so that the inner
assorted sizes, local manufacture. The purpose of these is to make sure surface on the wearer is exposed to the outside in the drum.
that nobody enters the theatre in ordinary clothes, or in clothes worn GLOVES, operating, sizes 6 to 8. Remember that gloves are designed to
elsewhere in the hospital. Everyone entering a theatre should put on a protect the surgeon as much as the patient. The type of gloves you buy is
theatre suit in the changing room, having taken off their outside clothes. critically important, and so is the relative number of the various sizes.
These suits should be laundered, and if possible ironed, but need not It is useful if they can be re-sterilized, when not soiled by their first use.
normally be sterilized each time they are used, unless they have been Most females wear size 6 to 7 and most males size 7 to 8. Pack each pair
used for septic cases. You should discourage the habit of staff who have in a cloth or paper envelope, one glove on each side with its cuff turned
been out of theatre in their theatre suits, coming back without changing. outwards. Gloves are more useful to protect you and the next patient,
than the patient you are actually operating on. Long arm-length gloves
are useful for septic or bloody laparotomy cases.
GLOVES industrial. These are useful for picking up hot objects, cleaning
floors and surfaces and used on the correct indications will save many
pairs of surgical gloves.
N.B. Avoid glove powder, especially starch or talc because it causes
granulomas particularly in the abdomen, and also is prone to produce
allergic reactions. Never use it when preparing equipment for
auto-transfusion.
SOAP, hexachlorophene, carbolic. If necessary, the cheapest soap that
does not irritate the skin will do. A liquid soap dispenser may prove not
only more efficient but more economical. Spirit disinfectants between
clean cases is effective and saves on soap.
BRUSHES, nylon, nesting, autoclaveable. Autoclave several of these
each operating day and store them between cases in a bowl of antiseptic
solution. They will last longer if you merely keep them clean and
immerse them in an antiseptic solution.
TOWELS, cotton, green, theatre. (a) Hand towels 25cm square.
(b) Theatre drapes 100x75 cm. (c) Abdominal sheets. An abdominal sheet
covers a patient completely from head to foot and has a slit in it through
which the operation is done. The upper end acts as a guard which keeps
the patient's head and the anaesthetist out of the operative field.
GASES. Cylinders need to be re-filled; if this is not possible, for a reliable
Oxygen supply, an Oxygen-concentrator, which extracts the gas from the
air, is very useful. Note that oxygen cylinders are black with a white top,
whereas Nitrous Oxide cylinders are completely black.
ANAESTHESIA DELIVERY SYSTEM. A ‘draw-over’ low pressure system
which is leak tolerant and uses air is far more reliable than a sophisticated
Boyle’s machine. Make sure equipment for airway management
(ambu-bag, mask, Guedel airways, ET tubes, laryngoscope with working
batteries and bulbs, and stethoscope) is always available.
HEATER to warm the theatre when it is cold (especially at night), and to
warm IV fluids and lavage fluid. Even in tropical climates, patients
(especially babies) can become hypothermic!
Fig. 2-4 SOME SURGICAL LAYOUTS. Other supplies: (1) Pyjamas and pyjama trousers. (2) Dresses.
This incorporates the theatre in 2-2 in progressively more developed (3) Macintosh drapes, 75x100cm. (4) Squeegees. (5) Bucket and mop.
settings. A, the absolute minimum. The changing is done in the
sterilizing room. B, similar but has an anteroom and staff changing N.B. Make sure extra staff can be found &called in case of
room. C, the arrangement recommended, which is x2-3 the cost of A. complications or emergencies.
(1) sluice. (2) scrub up. (3) sterilizing room large enough to prepare
sterile items for the rest of the hospital. (4) theatre table.
(5) anteroom. (6) changing room with shower and toilet.
(7) cupboard. D, further addition of (8), a minor (clean) theatre.
Adapted from Mein P, Jorgensen T. 'Design from Medical Buildings'
2.2 The minor theatre
AMREF, Nairobi, 1975 with kind permission.

CLOGS, assorted sizes. Rubber boots are outmoded; sandals are less easy A minor theatre for septic cases will help to maintain the
to keep clean and as they are open, provide inadequate protection. sterility of the major theatre. Use it for draining all
Use them only at the barrier between the theatre and the rest of the abscesses, and for the closed reduction of fractures.
hospital. It will need a simple operating table which tips, and a
APRONS, mackintosh, assorted sizes, local manufacture. These protect
the suits and are worn under a theatre gown. If they are merely hung up in second set of basic anaesthetic equipment, including
the changing room after use, they become progressively more especially a sucker and the equipment for resuscitation.
contaminated and more dangerous. So make sure that they are at least It will also need at least two minor sets (4.12), three
washed and regularly swabbed down with an antiseptic solution, and are incision and drainage sets. If possible the minor theatre
always swabbed after septic cases. Keep two for special clean cases only.
CAPS, cotton. Put on a cap before you enter the theatre, and make sure it should have its own instruments and not be supplied from
completely covers your hair (scalp & beard)! the main one.
MASKS, theatre. The use of these is controversial: if the surgeon has a Do not use this minor theatre for general anaesthesia (GA)
bad cold, he should better not operate. Most masks do not prevent cases.
passage of air-borne bacteria, and cotton muslin masks are useless.
They do protect against blood splashes, and should be used to cover a N.B. Remember there is really no such thing as minor
surgeon’s beard! surgery for the patient!

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2.3 Aseptic safe theatre technique

In order of importance, the most serious sources of

infection in a theatre are bacteria from:
(1) the pus and excreta left behind by previous patients,
especially on its equipment or towels, etc.
(2) the clothes, hands, skin, mouths, or perineal regions of
the staff; the bacteria on them may have been derived from
other patients.
(3) the patient himself.

Minimize the risk of infection by:

(1) following the design rules (2.1) as far as you can,
(2) washing your hands between patients,
(3) keeping the theatre as clean as possible, so that the pus
and excreta of previous patients are removed,
(4);making sure that all the autoclaving is done
conscientiously,
(5) following the rules about the indications for operating,
the timing of operations, wound closure, and careful tissue
handling,
(6) creating and maintaining the sterile zone in 2-1.

This sterile zone has to be created anew for each patient in

a theatre in which the risk of infection has been reduced as
much as possible. Its creation starts when a nurse swabs
the top of a trolley with antiseptic, puts two sterile towels
on it and lays out sterile gowns and gloves. The sterile
zone grows as the surgeon, the assistant and the scrub
nurse put on their gowns. The operation site joins the
sterile zone as it is prepared with an antiseptic solution and
draped. Thereafter, nothing which is contaminated must
touch anything in this zone until the end of the operation.
If the technique of the team is poor, the sterile zone
becomes smaller and smaller as the operation proceeds.

If you work on two sites on the body at the same

operation, start on the less septic site, and preferably use a Fig. 2-5 SCRUBBING AND GOWNING.
separate set of instruments for each procedure. A, make sure your mask covers your nose (if you wear one at all).
B, scrub your hands in a systematic manner. C, scrub your nails.
D, turn off the taps with your elbow. E, while your hands are wet,
As well as protecting the patient from sepsis, be sure to hold them higher than your elbows. F, blot your hands on one corner
protect yourself! Hepatitis B & C and HIV (5.3) are of the towel, then dry your forearms. G, hold the gown away from
serious risks, and transmission of these infections cannot your body, high enough not to touch the floor. H, ask the circulating
nurse to grasp the inner sides of the gown at each shoulder and pull it
be prevented by screening every patient or using special over your shoulders. I, how not to wear your mask! Do not put your
precautions in individual ‘high-risk’ cases. Always adopt hand in your axilla: it is not a sterile area, even after gowning!
danger-free zones for sharps. Be sure there is no direct
handling of sharps nurse to doctor, or vice versa. Wear wrap-around goggles when using high-speed drills,
Place knives and needles on syringes in a kidney dish in a and where large quantities of contaminated fluid are
‘no-man’s land’ where scrub nurse and surgeon never put expected.
their hands at the same time. Remove sharps by Double-gloving decreases the risk of needle-stick injury,
instruments and not by hand, and dispose them in specially but does not eliminate it. You can use re-sterilized gloves
designated containers for incineration. You should try to for the first layer to reduce costs. Some surgeons prefer to
avoid using sharp retractors, skin hooks, and cutting put on one pair ½ a size larger on the outside, or on the
needles wherever possible. Do not use your hands as inside.
retractors. Do not try to find a needle lost in the tissues Different coloured gloves may show up an accidental
with your fingers. perforation more easily.
You can wear special Kevlar needle-proof gloves inside,
Handle needles with instruments; cut the needle off before but they tend to be cumbersome, especially for fine
tying a suture, or hold it at its sharp point with the surgery (5.3).
needle-holder.

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ENTERING THE THEATRE. Anyone entering the theatre Rub your hands and forearms to 5cm above your elbows
must change, in the changing room, into clogs and into a thoroughly. Wash your forearms and your hands.
theatre pyjamas or dress. This is important also when Then take a sterile brush and put soap on it. Scrub your
someone has left the theatre (in theatre attire) for the wards nails (2-5C), thoroughly for the first case in the day.
or casualty (accident & emergency) department, N.B. Make sure all surgical staff keep their fingernails
and returns. (Many hospital routines concentrate on short, and have long hair tucked away!
putting on overshoes, gowns etc. on leaving the theatre; Rinse the suds from your hands while holding them high,
more important is to change again on re-entering.) so the water runs off your elbows (2-5E).

You must insist that theatre clothing is not just worn over Turn off the taps with your elbows, if this is possible
ordinary outside clothes. Clogs are better than boots, (2-5D); otherwise ask someone else to do it. Blot your
which become sweaty and smelly. Tennis shoes are hands dry on one corner of a sterile towel (2-5F),
an alternative to clogs but get soaked by fluids. taken from the gown pack without contaminating the gown
However, you can likewise soak them to clean them! itself. Then dry your forearms, using a different (dry) part
of the sterile towel.
There is no proof that masks are helpful, except in
protecting the surgeon (or nurse) from splashes. A sneeze If you can get disinfecting spirit for the hands, you only
passes through all masks; a person with a bad respiratory need wash with soap initially or after septic cases;
infection should not be in theatre at all! Masks are an it is easy to become slack with any method.
unnecessary expense.
GOWNING. Hold the gown away from your body,
POSITIONING THE PATIENT high enough to be well above the floor (2-5G).
Allow it to drop open, put your arms into the arm holes
Do this carefully before you scrub, so that you do not have while keeping your arms extended. Then flex your elbows
to disturb him by altering the drapes or lights during the and abduct your arms. Wait for the circulating nurse to
operation. Make sure IV lines, catheter, nasogastric tube help you. She will grasp the inner sides of the gown at
are in place and functioning. Check that there is sufficient each shoulder and pull them over your shoulders, and tie it
room for you, the anaesthetist, the scrub sister and an at the back (2-5H). Do not touch the outside of your gown
assistant (or two). till you have sterile gloves on.

If you use diathermy, place the earth plate in contact GLOVING. Try to avoid using glove powder even if you
with the skin of the buttock or leg before draping. are using re-sterilized gloves. Be careful to touch only the
Make sure it has been tested, e.g. on a bar of soap. inner surface of the gloves. Grasp the palmar aspect of the
turned down cuff of a glove, and pull it on to your opposite
Pay close attention to pressure points, particularly in hand (2-6A).Leave its cuff for the moment. Put the fingers
emaciated patients, and when legs are put in lithotomy of your already gloved hand under the inverted cuff of the
position. other glove, and pull it on to your bare hand (2-6B).
Holding the sleeves of your gown tightly folded against
If a patient is in the lithotomy position, make sure he is your body, pull the glove over the wrist. Then do the same
pulled down sufficiently so that the perineum is then quite for the other hand.
free from the end of the bed. Make sure the legs do not fall N.B. If you do use powder, always wash it off your
out of the stirrups! gloved hands with sterile water to remove it completely.

If a patient is prone, make sure the abdomen is free to Now help the next person who has gowned on with the
move with respiration. Fold the arms under a pillow on gloves.
which the head, turned to one side, is resting. (If you wear 2 pairs of gloves, you may prefer to put the
first pair on before gowning. The 1st pair could be one that
If a patient is in the lateral position, make sure he is has been re-sterilized.)
cushioned and supported, and there is a pillow between the
knees. You may prefer to ask the already scrubbed, gowned &
gloved theatre nurse to hold open the gloves, with the cuffs
Make sure the theatre lights are directed correctly once everted, for you to slip your hands inside. This is easier
you have pumped the theatre table to an agreeable height. and a safer method, but relies on the scrub nurse’s gloves
being sterile!
SCRUBBING UP. Remove any jewelry. Open a gown
pack without touching the inside of the pack. Check that it MAKE SURE YOU HAVE FOLLOWED THE
is properly autoclaved. Adjust the taps to deliver water at a CAUTIONS LISTED (1.8)
comfortable temperature. In most tropical countries only a
cold water tap is necessary. Wet your hands, apply a little It is a good idea if using local anaesthetic to infiltrate
soap or detergent, and work up a good lather. before scrubbing, in order to allow it time to take effect.

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THE OPERATION SITE Clip them at their intersections. If the towels are in danger
of falling off, secure the towels with a stitch. Do not clip
Make sure the patient has bathed before the operation and the skin with clips as this may cause skin necrosis.
the operation site is clean. Remove any jewelry or skin For an abdominal operation, cover the whole abdomen
piercing. with an abdominal sheet with a narrow quadrangular hole
Check the side to be operated upon. Make sure it is in its centre.
marked with a permanent marker. If not, confirm the side Remember to complete the draping at the beginning of the
with the anaesthetist and scrub nurse. operation if more than one operation site is needed,
Put a septic limb to be amputated in a plastic bag already e.g. for skin grafting. Make sure the perineum is securely
on the ward and seal the bag with wide tapes onto the leg. covered, and that drapes round limbs are secured snugly
In the theatre cover the bag with sterile towels. with clips or bandages. You can cover a hand or foot by
Take the amputated limb out of the theatre before putting on an extra large sterile glove and inverting it over
recovering the towels. the extremity.
Check the position of the patient on the table yourself. If the patient is awake (e.g. with spinal anaesthesia)
put drapes across two drip stands to separate the head from
SHAVING. The operation site should be socially clean the operative field. If important areas near the surgeon
before the operation, and you may have to check this. become contaminated, remove them and cover the patient
There is usually no absolute need to shave a patient. with fresh sterile towels.
If you shave or clip the hair, do so on the morning of the
operation, or as part of the operation, and limit this to a SUCTION TUBING & DIATHERMY. Secure these to the
narrow zone (2-5cm) around the planned incision. drapes securely with towel clips, so they do not fall off
Make sure you remove the cut off hair (this can be done during the operation.
with an adhesive tape and washing); otherwise the hair
will end up in the wound. SWABS AND PACKS. Use 10cm gauze squares on
If you do the shaving a day or two before, minute sponge-holding forceps ('swabs on sticks'). You will also
abrasions in the skin will become infected and the risk of need abdominal packs. Make sure these are counted and
wound infection will increase. Betadine shampoo checked at the end of each operation, and then disposed of
especially of the head and groin is particularly useful after quickly in the sluice.
shaving.
CLEANING THE THEATRE. Remove clutter. Wash the
SKIN PREPARATION. Do this as soon as the patient is floor and clean the table and accessories after each
anaesthetized. Use an alcoholic-based solution, preferably operation. Clean the theatre thoroughly after each day's
iodine, if possible: check for the patient’s sensitivity. list, and completely every week. Fumigate after a septic
Take a sterile swab on a holder, start in the middle of the procedure with formalin.
operation site, and work outwards. Be sure to prepare a
wide enough area of skin, including any additional areas CLEANING INSTRUMENTS. Use an old nail-brush.
needed for example in skin-grafting. In an abdominal Open hinged instruments fully, scrub them, and take
operation this should extend from the patient's nipple line special care to clean their jaws and serrations.
to below the groin. Beware of sharps!
N.B. Make sure the alcohol-based solution dries
because of potential burn hazard if you use diathermy. DIFFICULTIES WITH ASEPTIC METHODS
Avoid spillage under towels, and seepage under a If you have no gloves or very few gloves, scrub up and
tourniquet where it may remain in contact with skin for a then rinse your hands and arms in alcoholic chlorhexidine
long time and cause irritation. (2.5). The alcohol will dehydrate your skin. You can
N.B. There is no justification for using skin preparation reduce this by adding 1% glycerol to the solution.
twice. Unfortunately, although antiseptics may help to protect the
patient, they are not effective in protecting you from HIV
CATHETERIZATION. For major abdominal and pelvic (5.3) so use a ‘no-touch’ technique, using instruments
operations, catheterize the bladder using an aseptic between you and the patient. Limit your operating to
technique (27.2) before draping. Do not catheterize emergencies.
routinely for other abdominal procedures. Change your
(outer) gloves: these can then be re-sterilized. N.B. If you tear or contaminate a glove during an
operation, remove it. Grasp its cuff from the outside, and
DRAPING. Wait until the patient is anaesthetized. Aim to pull it down over your palm. Alternatively, if it is not
leave the operation site alone exposed and all other parts soiled, put on another sterile glove on top over it,
covered. Place the first towel across the lower end of the in the same way as described above.
operation site. Place another across its nearer edge.
Apply a towel clip at their intersection, under the folds of If you have no drapes or gowns or very few of them,
the drapes. Place another towel across the opposite edge of use plastic sheets and aprons and soak them in an
the site, and finally one across its upper edge. antiseptic solution (2.5).

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The basis of aseptic surgery is to kill all micro-organisms

on all instruments and dressings, preferably by exposure to
steam under pressure. If this is impractical, immersion in
boiling water for 10mins at sea level will kill all viruses
and all vegetative bacteria, but not spores, particularly
those of tetanus and gas gangrene. A boiling water
'sterilizer' is therefore badly named. At a height of 3,000m
above sea-level water boils at 90oC and is much less
effective.

Steam is simply the gaseous form of water; if it is to

sterilize effectively, which means killing all spores:
(1) It must be at an appropriate temperature (which implies
an appropriate pressure).
(2) It must be saturated with water.
(3) It must not be mixed with air, so it must displace all the
air in the chamber of the autoclave.
(4) It must reach all parts of the load.

If it contains droplets of water, it will soak into porous

materials. If, on the other hand, it is superheated and
therefore too dry, it will be less effective as a sterilizing
Fig. 2-6 PUTTING ON GLOVES. agent. If air is mixed with steam:
A, take hold of the inside of the glove with your right hand, and put
your left hand into it. B, put the fingers of your left hand under the
(1) The temperature of the mixture at a given pressure will
cuff of the glove. C, pull your right glove on without touching your be lower,
wrist. D, the first person to glove up (usually the scrub nurse) now (2) It will penetrate less well into porous materials,
gloves the second person (usually the surgeon), by holding out the (3) The air may separate as a lower, cooler layer in the
gloves for him like this.
bottom of the chamber, so that the contents are not
WOUND SEPSIS AND THE ART OF SURGERY sterilized. If no air is discharged, the bottom of the
‘In summary, I believe that regard for tissue is the foremost of our chamber may be much cooler than the top.
priorities. Let us strive to become first class surgeons, and let us train
considerate disciplined theatre staff. Let us have plenty of soap and water,
or some not too corrosive detergent. We do need sterilizers and
As soon as the chamber of an autoclave is full of steam at
autoclaves. We need well ventilated rooms which are light and easy to the desired temperature and pressure, it must be held there
clean, and where the number of additional items is kept low. We should for a critical time, the holding time. The standard holding
don theatre attire, should indeed change frequently, and should certainly time is 15mins, at 121oC, but you will need to vary it as
change our masks. Gloves are important though not indispensable.
Use sharp knives, few instruments and keep things neat and clean.
described below. This temperature is reached at a pressure
Do not bury undue amounts of biologically irritating material in the of about 1kg/cm² (15psi). An easy minimum figure to
tissues. Beware of haematomas and lymph collections. Use suction drains remember is ‘1kg/cm² for 15mins’ (‘15lbs for 15mins’).
frequently. Use delayed primary closure where this is indicated. If your autoclave is rated to 1·3kg/cm², you can shorten the
In the wounds you make yourself, bring the skin edges together carefully
so that the wound is sealed in a few hours. Hydrate your patient, and do
sterilizing time to 10mins. Here we only discuss the
not oversedate him. Avoid stasis by elevation and movement. simpler forms of autoclave; high vacuum autoclaves are
Use dressings sparingly, and observe the wound. If you find a haematoma beyond the scope of this manual. Single walled autoclaves
and evacuate it speedily you will prevent sepsis’ Loefler IJP, Wound are strong metal chambers with water in the bottom,
sepsis and the art of surgery. Proc Assoc Surg E Africa 1979;2:172-180
similar to large pressure cookers. They have several
disadvantages:
(1);The air in the chamber is removed by steam rising
2.4 Autoclaving from the bottom. This is inefficient, so that an undesirable
quantity of air remains.
(2);They do not have thermometers at the bottom of the
Sterilization literally means destroying the fertility of chamber, so you never know what the temperature there is.
organisms; in the hospital context it describes the (3) The load remains moist after sterilization, which can be
elimination of all forms of contaminating organisms, dangerous, because bacteria can more easily enter through
including bacterial spores. Nitrogen dioxide (NO2) is best; moist wrappings.
otherwise use heat, either dry heat in an oven, or steam Double walled autoclaves can be vertical, but are much
under pressure in an autoclave. Processes (usually better horizontal. They should either have an effective
chemical) which do not destroy spores are termed pre-vacuum, or a pulsing system (neither described here),
'disinfection'. Some of the most important agents to be or rely entirely on gravity to displace the air.
removed by disinfection are HIV, HBV & HCV (hepatitis A partial pre-vacuum at the start of the sterilizing cycle
B & C virus). All the disinfectants mentioned (2.5) will do (which used to be the practice in some older autoclaves)
this if used as directed. If no alternative is available, causes turbulence when air is admitted, so that the gravity
hypochlorite is suitable for most purposes (5.4). displacement of air cannot take place satisfactorily.

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Steam is generated in, or admitted to, a jacket round DRESSING BOXES, stainless steel, with hinged lid and perforated
sliding shutters at front and back, 250x200x150mm. Use these for
the chamber, rather than in the chamber itself.
sterilizing gloves and dressings.
This jacket keeps the walls of the chamber hot, which TRAYS, dressing, without lids, stainless steel, 275x320x50mm.
prevents condensation and helps to dry the load. Use these to prepare sterile sets for the wards. Boil a tray and the
Steam enters the chamber through a pipe at the top and instruments, lay a sterile towel on the tray, put the instruments on it and
fold it over them. Better, autoclave the tray.
displaces the air it contains. Air, condensate, and excess
steam escape through a pipe at the bottom. This pipe has a
thermometer in it to record the temperature in the bottom
of the autoclave.
In some autoclaves a water pump, which works on the
same principle as an ordinary laboratory water pump,
sucks out some of the steam afterwards (post-vacuum).
There is also a means of admitting sterile air to break the
vacuum at the end of the cycle.
The drain at the bottom of the chamber should have a
'near-to-steam trap', which will allow the discharge of
condensate and air, and will close automatically when they
have been discharged, and the trap meets live steam,
thus avoiding the need to close valve 13 (2-7) manually,
which could spoil sterilization.
The thermometer records the temperature in the chamber
drain, which is the coolest part of the autoclave.
When this reaches the operating temperature, the timing of
sterilization can begin.
More sophisticated autoclaves have better pumps,
a recording thermometer, a thermocouple to measure the
temperature of the load, and an automatic control system.
Inadequate sterilization is an important cause of wound
sepsis in poorly maintained theatres.

AUTOCLAVE, horizontal, downward displacement with near-to-steam

trap in the chamber drain, post vacuum, six spare gaskets, three spare
bellows for the steam trap, and a triple set of other spares. If you have a
steam supply, this is the autoclave you need. Horizontal autoclaves are
easier to use, but are more expensive. You will need a standby, in case
the electricity fails, so you should have an autoclave that can be heated by
kerosene or gas somewhere in the hospital (see below).
Or, AUTOCLAVE, vertical, downward displacement, 350 mm, 2½ drum,
electric, 6kW, state voltage, manual operation, with six spare elements,
six spare gaskets, and a triple set of other spares as necessary.
AUTOCLAVE, vertical, 350mm, 2½ drum, for heating by gas, manual
operation, with 6 spare gaskets, and a triple set of spares as necessary.
Fig. 2-7 AUTOCLAVES.
This is for use in emergency, see above.
A, simple autoclave is a strong metal chamber with water in the
AUTOCLAVE, vertical, 'pressure cooker', 47L, UNICEF. This is a large
bottom, like a large pressure cooker.
autoclave which can be heated on a stove and has a machined lid so that it
B, jacketed vertical gravity displacement autoclave. This is filled
needs no gaskets. It is large enough for 5lof intravenous solution, or one
through a tundish (open funnel) (1) and a filling valve (2). On the
laparotomy pack. It is a useful standby. It has an air exhaust tube which
same pipe there is a safety valve (3) and a pressure gauge (4) to
leads from the exhaust port to the bottom of the sterilizer. If you use it,
measure the pressure in the jacket. A pressure switch (5) controls the
you can start timing as soon as steam comes from the exhaust.
pressure in the jacket and an indicator (6) monitors its water level.
TUBES, Browne's, for testing autoclaves, Type 1 (black spot), for use
A float switch (7) cuts off the power if the water level is too low, and a
with ordinary steam sterilizers below 1260C. These change colour on the
drain tap (8) lets water out of the jacket. Several heating elements (9)
basis of time and temperature, and are reliable, provided that there is not
heat it. The chamber is drained through a pipe (10) and a strainer
a long drying cycle, when prolonged heat in a jacketed sterilizer could
(11). A thermometer (12) and a valve (13) are fitted to the drain pipe
change their colour.
(the valve should be an automatic near-to-steam trap, preceded by a
Or, CARDS, autoclave testing, ATI 'Steam-clox'. This brand of tape
non-return valve, to prevent dirty air and some water being sucked
changes colour on the basis of moisture and temperature, to indicate that
up during the vacuum). Steam from the jacket is admitted to the
something has been autoclaved. Most other brands of autoclave tape are
chamber through valve (14). Pressure and vacuum in the chamber
only suitable for high pre-vacuum autoclaves, not for the downward
are measured by a gauge (15). Air is admitted to the chamber
displacement ones described here. Another alternative is 'Diack through a valve (16) and an air filter (17). Air and steam are
Control', a pellet in a glass tube which melts at 121 or 1260C. discharged from the chamber through valve (18) by means of the
DRUMS, deep, 340x230mm. This is the standard size of drum. water-operated ejector pump (19) operated by tap (20).
DRUMS, shallow, 340x120mm. These are half- size drums. C, vertical gravity displacement autoclave. Steam is admitted fairly
You may have difficulty getting drums because they are no longer used in high up the sterilizer. The drain with the thermometer is as near the
the developed world. If you are short of drums, sterilize your equipment chamber as possible. There is a near-to-steam trap separated from
in packs, covered by two layers of towelling and preferably an outer layer the drains by a tundish, which prevents dirty water being sucked
of paper. If you are sterilizing without paper, use all equipment warm back up the waste pipe into the autoclave during a vacuum phase.
straight from the autoclave. D, 'near-to-steam trap' (valve) in the waste line remains open, until
steam following the air heats the bellows under the diaphragm and
closes the trap automatically. C,D kindly contributed by Ronald Fallon.

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CAUTION! Let the air and the steam escape freely until
STERILIZER, boiling water, electric: (a) 'Bowl sterilizer',
there is no more air in the autoclave, this usually takes
450x350x380mm, with counterbalanced lid, 6 kW, with six spare
elements, state voltage. (b) Instrument sterilizer, 350x160x120mm, about 10mins. To test this lead a rubber tube from the
1·2kW, with 6 spare elements, state voltage. One of these is for trays and discharge tap into a bucket of water. When air no longer
bowls, and the other for instruments. Keep them both in the preparation bubbles to the surface, there is no more air. After some
room. Never try to sterilize anything contaminated with faeces with
trials you will learn how long to allow for this to happen.
boiling water in a sterilizer - it does not destroy spores.
FORCEPS, (2) sterilizer, Cheatle's, 267mm, Close the discharge tap. Let the temperature rise until it
FORCEPS (2) sterilizer, Cheatle's extra large, 279mm, complete with reaches 121ºC. The safety valve will open and allow steam
can of appropriate size for antiseptic fluid. These are useful for bowls to escape. It should come out with a pure hissing sound
and utensils, and will also pick up small objects.
rather than gurgling indicating the presence of air.
FORCEPS, bowl sterilizing, Harrison's double jawed, complete with can
of appropriate size for antiseptic fluid. Autoclave these and Cheatle's Now start to measure the holding period and continue this
forceps and their cans after each day's use, then fill them with fresh for 15mins. Then, turn off the heater and allow the
antiseptic fluid. autoclave to cool, until the pressure gauge records zero
pressure. Do not open the autoclave whilst the pressure is
Many hospitals do not have piped steam supplies. still high: you might be badly burnt! Then open the
If so, use a vertical autoclave. Your electricity supply may discharge tap and allow air to enter the autoclave.
be unreliable; think about using an alternative such as gas. Remove the load.
There are many pitfalls. Start by inspecting your CAUTION! If anything in the load has paper or cloth
equipment and taking an interest in it. Read the maker's wrappings, do not allow them to touch anything unsterile,
instructions carefully, and make sure that: until they have dried, because microbes can penetrate wet
(1);it has been properly fitted and tested. For example, paper.
if a water ejector pump is fitted, it is likely to need a water
pressure of 1·5kg/cm². JACKETED AUTOCLAVE (2-7B)
(2);all the staff who use it understand how it works,
and how to use it effectively. They must realize the Keep the jacket full of steam at 121ºC throughout the
importance of packing the drums loosely, the need to working day. Drain the chamber to remove any water that
discharge the air, and the correct holding time. may gather in it. Load the heated chamber, close the lid,
and open valve (13).
STERILIZING WITH MOIST HEAT
BOILING WATER STERILIZING. Open valve (14). When the temperature
on thermometer (12) has reached the sterilizing
Make sure that every article for sterilization is cleaned temperature (usually 121ºC), the holding time can start.
thoroughly to remove dried blood, pus or secretions before Close valve (13). If it is letting much steam through,
it is sterilized. Remove instruments from boiling water the temperature will not reach 121ºC, until it is closed.
with long-handled Cheatle's forceps which have been in So close it as soon as no further air and condensate come
saponated cresol ('Lysol') up to their handles. If you are out of the chamber. If you still do not get the temperature
not wearing sterile gloves, make sure you let the you need (usually 121ºC), open valve (13) for a minute or
instruments dry. If you use them wet, bacteria from your two and try again (a near-to-steam trap does this
hands may flow down from your fingers in drops of water. automatically). When the temperature has been reached,
start timing.
PACKING ANY AUTOCLAVE CAUTION! Do not infer the temperature from the
reading of the pressure gauge. This may give you an
Sterilization is impaired by anything which hinders the inaccurate indication of its temperature and is a common
removal of air, so arrange the contents loosely; cause of sterilization failure.
a drum which can only be closed with difficulty is grossly
overpacked. Place the contents so that air can readily be POSTVACUUM (drying). Open valve (20), then valve
displaced downwards: the principles are the same in (18). Leave them open for 15-20mins. Close valve (18)
horizontal and vertical autoclaves. This means packing the then valve (20).
items vertically rather than horizontally. To avoid air
pockets, interleave sheets of mackintosh or jaconet with TO BREAK THE VACUUM. Open valve (16).
some permeable fabric, so that no two surfaces of the
non-permeable material are in contact. TESTING AUTOCLAVES
If you are using Browne's tubes, put a tube in the centre
A SIMPLE AUTOCLAVE (or pressure cooker) (2-7A) of the load, with, if possible, one on the outside to show
that the autoclave has indeed been switched on!
Make sure there is enough water in the bottom of the
autoclave. Insert the drums to be sterilized, and turn on the If you do not have Browne's tubes, put some dry earth in
heater. See that the discharge tap is open, and then screw an envelope, autoclave this and then culture it in a bottle or
down the lid. As the water boils the steam will rise and tube of nutrient broth. Spores may be slow to grow,
carry away the air in the autoclave. so incubate it for a week. If even this is impossible,
put an egg in the middle of a drum to see if it is hard
boiled!

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PARTICULAR PROCEDURES FOR AUTOCLAVING There is an optimum antiseptic for each purpose, so try to
The following figures are guidelines only and vary with use the right one.
the type of autoclave and the size of the load. Disinfectants have serious limitations and only work
They apply to a sterilizing temperature of 121ºC. when the object they are disinfecting is clean:
Empty glassware & unwrapped instruments. they are ineffective in the presence of blood or pus.
Sterilizing time 15mins, drying 10mins. So wash scissors and fine instruments carefully before you
Wrapped instruments, rubber gloves, tubes & store them in an antiseptic solution. If possible, drains and
catheters, and sutures being re-autoclaved. other heavily contaminated pieces of equipment should be
A common regime is 0·7kg/cm² (10psi) for 20mins. boiled or autoclaved after washing and before being
Fabrics & dressings. Sterilizing time: 20mins, immersed in these solutions. Afterwards, wash them well
drying time: 15mins. in sterile water before you use them. Catheters and tubes
Liquids in flasks and bottles. etc. deteriorate in antiseptic solutions and are better
Sterilize bottles according to size & time as follows: autoclaved before use.
mls 100 300 500 1000 3000 Avoid cetrimide: it is mainly a detergent; chlorhexidine is
mins 20 30 35 40 50 better.
Switch off the heat and let the autoclave cool down.
Do not open it until the pressure is zero, as the bottles may
burst.

PREVENTIVE MAINTENANCE
Follow the maker's instructions carefully. Don’t miss out
on this for reasons of false economy or ‘permanent’ need!

DIFFICULTIES WITH DOWNWARD DISPLACEMENT

AUTOCLAVES
If the temperature falls below 121ºC, while the
pressure remains at 1 kg/cm² (15psi), the outlet from the
chamber may be blocked, and the chamber full of air.
Check it daily.
If you work at high altitudes, for each 300m
(1000 feet) you are above sea level, increase the time you
immerse things in boiling water by 5mins, and increase the
pressure of your autoclave by 0·03 kg/cm² (½psi).
Water above 80ºC will kill all vegetative organisms and
viruses; boiling water is still effective at 4,000m
(13,200 feet).
If dressings are wet after autoclaving, the steam is
probably wet, due to: (1) inadequate lagging of the steam
supply pipe, or (2) inadequate tapping of condensate.
If you have reason to suspect imperfect sterilization,
run the tests above. Also check that:
(1) The drums are packed properly.
(2) The correct temperature and sterilizing times are used.
(3) The chamber drain is not blocked.
(4);The drums are not being re-contaminated after
sterilization.
STERILIZING WITH DRY HEAT
Use this for laboratory items, knives, drills which do not
tolerate steam well. You need a higher temperature
(160ºC) for 1hr.
Although heat is the best way of killing micro-organisms, Fig. 2-8 PACKING AN AUTOCLAVE.
it is not appropriate for delicate instruments, rubber or a A, orientate a load to facilitate the escape of air in a gravity
person’s skin. Heat also destroys a cutting edge, so store displacement sterilizer. Steam enters from the top, flows downwards
your scissors in a chemical solution which will destroy through the load and displaces the air in it. B, pack a glove container
properly. C, folded glove lined with gauze. D, a pair of gloves packed
bacteria. Classically, these chemicals are either antiseptics, in a fabric envelope. E, fabric envelope on edge to show its correct
which are safe to use on the surfaces of the body, position during sterilization. F, pack the drum correctly with open
or disinfectants, which are not. In practice, the distinction ports positioned to allow air to be displaced by gravity. G, turn glove
is not precise, and the only substances in the list below containers in an autoclave on edge so that steam can displace air
through them.
which cannot be applied to the body are saponated cresol After Sterilisation by steam under increased pressure; a report to the
('Lysol'), formalin, and glutaraldehyde. Medical Research Council by the Working Party on Pressure-Steam
Sterilisers. Lancet 1959;7070:425-35, with kind permission.

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2.5 Disinfectants & antiseptics Aim to sterilize everything coming into contact with the
wound by soaking it for a sufficient time in an antiseptic
solution. Unfortunately:
SKIN. Any alcoholic solution will do. Alcoholic iodine is (1) An antiseptic solution leaves everything wet.
best: use it routinely, except in children, on the scrotum, (2) Sterilization is slow so that you may only be able to do
and in allergic patients. Chlorhexidine 0·5% in spirit is a one operation at a time.
less satisfactory alternative. Apply it to the skin after (3);Wide areas of the body are exposed to the antiseptic,
removing all traces of soap. which causes much exudation from the wound.
Even so, antiseptic surgery is simple, and makes many
WOUNDS. There is no substitute for a scrubbing brush, kinds of operation possible. If necessary, you can combine
plenty of water from a jug, and a thorough surgical toilet. antiseptic and aseptic methods, and sterilize smaller
Chlorhexidine is useful for cleaning the skin round a instruments in a pressure cooker. Chlorhexidine is the
wound. most practical antiseptic, but is far from perfect.
INSTRUMENTS, SUTURE MATERIALS, & DRAINS. ANTISEPTIC SURGERY UNDER ADVERSE CONDITIONS.
The following agents are effective against HIV and HBV, “The only means of access to our hospital at present is by walking over
in addition to the classical pathogens (5.4). the mountains for a week. All supplies have to be carried in by porters
who take two weeks for the journey. For the first 2½yrs, we worked in a
(1) 0·55% ortho-phthalaldehyde. traditional Nepali house with a thatched roof and a floor made of mud
(2) 2% alkaline buffered glutaraldehyde. and cow dung. In it we did over 100 operations by the antiseptic method,
(3) 8% formalin in 70% spirit or as a tablet. without serious mishap. Later, limited space became available, so that
(4);A 0·5% solution of chlorhexidine in 70% spirit with although we enjoyed the advantages of tap water, a concrete floor, a clean
ceiling, and adequate window ventilation, we still had to operate on a
0·5% sodium nitrite. (This is in terms of the active agent.) light outpatient type of table and in the same room in which the
(5) Plain 70% spirit. outpatients received all their medicines, injections, dressings, incisions,
The first 2, ‘Cidex OPA’ and ‘Cidex’, are the best; and dental extractions. We almost always used epidural or local
glutaraldehyde needs to be activated before use but anaesthesia”. Dick JF, Surgery under adverse conditions, Lancet
1966;7469:900.
ortho-phthalaldehyde does not.
10mins is the absolute minimum time in these solutions,
ANTISEPTIC SOLUTIONS.
provided instruments are scrupulously clean, 24hrs is
Use chlorhexidine 5% concentrate to make two solutions:
safer. Ideally, nothing should be considered 'sterilized'
(1);A weak solution of 1/2000 of the active agent in water.
until it has been immersed for 24hrs. Wash all equipment
Use this for soaking towels, etc.
well before using it.
CAUTION! (2);A strong solution for instruments, as described (2.5).
(1);Except for glutaraldehyde (which can be used for Make up small quantities of solutions frequently, make
them up hot, and clean out the containers well between
14-28days depending on the brand) you must prepare these
batches.
solutions freshly every week, and keep them covered to
prevent the alcohol evaporating.
STERILIZING EQUIPMENT AND DRAPES.
(2) A 'wipe' is not nearly as good as a soak!
N.B. Formalin tablets can be vaporized in special Soak everything which will come into contact with the
chambers and used to sterilize endoscopes over 12hrs. wound in one of these solutions for at least 30mins.
Soak sutures and gloves in this solution overnight.
It is irritant to the eyes, and nose, and toxic to the tissues.
Use monofilament (4.6) for ligatures and sutures, and the
It is useful for fumigating the theatre after a septic
minimum number of simple instruments.
procedure.
The most appropriate drape, for a tubal ligation, for
FURNITURE, DOORS; WINDOWS & OTHER example, may be a single solution soaked plastic sheet
long enough, and wide enough, to cover the whole patient,
FIXTURES
with a hole in the middle through which to operate.
5% phenol (carbolic acid) is a satisfactory cleaning agent;
If you have 2 such drapes, one can be in use while the
you can use a 10% solution for very soiled surfaces.
other is being soaked in a flat container of solution.
CAUTION! Do not use syringes and needles soaked in
antiseptic to give a subarachnoid or epidural anaesthetic.
2.6 Antiseptic surgery
WHILE OPERATING, treat the patient's skin with the
solution for at least 2mins before the operation.
This used to be standard practice before aseptic methods
Wash your hands as usual and put on the wet gloves.
made it more or less obsolete. But it may still be useful
Wring out the soaked drapes as dry as you can, and apply
when power supplies have failed or your autoclave breaks,
them as near as possible to the operation site.
or an important operation has to be done in some remote
Clean the patient's skin with the same solution.
place. It has been said that a first-class surgeon can
operate in any theatre in any clothes in any situation.
If there is a danger that he might get cold,
However, even if you are not an expert, do not deny
cover him with a dry blanket in a plastic sheet, and put this
someone life-saving surgery if your autoclave has stopped
between the skin and the wet towels above and below the
functioning!
operation site, where it will not get in the way.

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Swab the trolley with the solution, or put the instruments For prophylaxis use a single dose of antibiotic: this is
on a solution-soaked towel. Keep 2 bowls near the indicated in ‘clean, contaminated’ (category 2) cases such
operating table, one containing water and the other as hysterectomy, Caesarean Section, appendicectomy,
antiseptic solution. cholecystectomy.
When instruments have been used, wash them in water and N.B. Clean uncontaminated wounds (category 1) do not
keep them in the solution until you use them again. benefit from antibiotic prophylaxis.
Shake off the excess solution before you use them. Even with immunocompromised patients you should not
Handle the tissues as little as you can, and try to keep the change this principle.
solution out of the wound as much as possible.
Do not let cleaning solution get into the body cavities. That said, how can you use antibiotics for invasive sepsis
to the best advantage, when your laboratory staff cannot
AFTER OPERATING rinse everything free of blood. culture bacteria, or at least not reliably? You can learn
Rinse the instruments, and put them away. much, however, from a simple Gram stain. Nonetheless,
If the wound is well sutured and is not expected to encourage the laboratory to examine blood cultures, which
discharge, leave it open to the air. are not difficult technically, and, when these are positive,
to isolate the organism responsible for septicaemia in pure
culture.
If you are fortunate, you will be able to plan a logical
2.7 Antibiotics in surgery antibiotic policy for your district, and keep some
antibiotics for hospital use only, in the hope that the arrival
Antibiotics have 2 uses in surgery: of antibiotic-resistant strains from elsewhere in the world
(1) To treat invasive sepsis. will be delayed as long as possible. In such an ideal
(2) In certain circumstances only, and when used in a very situation you might decide, for example, that the clinics
particular way, as prophylaxis to prevent postoperative should use only penicillin and tetracycline, with perhaps a
infection. little ampicillin or trimethoprim; keep streptomycin for
tuberculosis only. This will enable you to use
They are less important than: chloramphenicol with metronidazole as your main surgical
(1) Careful aseptic theatre routines. antibiotics, especially when the gut and the genital tract
(2) A thorough wound toilet. are involved. For other occasions you can use gentamicin,
(3) Delayed primary closure. or a cephalosporin.
(4) Making sure there are no foreign bodies, dead tissue, Unfortunately, you are more likely to work in a situation
excessive blood clots, or faeces in the wound. of antibiotic chaos, in which any antibiotic is obtainable
over the counter without prescription, and where multiply
In preventing sepsis, antibiotics give you no licence to resistant strains, particularly those resistant to
neglect the classical rules of good surgery, especially if chloramphenicol, are common. Be sure to find out what
the patient is diabetic, very old, has HIV and is very ill, are the sensitivities and so the antibiotics of choice for
and so is less able to overcome any bacteria that cause your area. You should get a good idea of which antibiotic,
infection. out of those generally available, to use for which situation.
Antibiotics will represent a very large part of your You may have donations of expensive newer antibiotics:
pharmacy’s budget, so use them wisely and not do not waste them through ignorance of their benefits!
indiscriminately.

Generally speaking, antibiotics are prescribed far too

often, far too long, and with far too little thought.

So:
(1) Handle the tissues gently; take care to avoid spillage
and contamination of the wound.
(2) Do not leave large pieces of dead tissue in the wound,
such as huge, massively ligated pedicles, or with excessive
use of diathermy.
(3) Do not put tissues or skin under tension.
(4) Make sure there is secure haemostasis.
(5) Divert faeces if they risk contaminating a wound, by
temporary colostomy.

Differentiate from prophylactic use of antibiotics (2.9) Fig. 2-9 ANTIBIOTICS MUST GET TO THE PATIENTS AND
and the treatment of invasive sepsis (e.g. cellulitis, THE DISEASES WHERE THEY CAN DO MOST GOOD.
A poster from Oxfam's 'Rational Health Campaign' to show the
septicaemia). enormous burden many communities bear in misused antibiotics that
are bought in the market-place, or are prescribed by doctors on the
wrong indications for the wrong patients.
Kindly contributed by Oxfam.

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2.8 Particular antibiotics The others: azithromycin, clarithromycin,

roxithromycin have slightly better activity against
Gram-ve organisms, but are expensive.
Some antibiotics are particularly important in district
hospital surgery, either because they are life-saving, METRONIDAZOLE (400mg tid) is effective against
or because they are good value for money. anaerobes (which far exceed aerobes in the gut, and are the
Do not, however, overuse them, particularly when there is cause of foul faecal odour), especially Bacteroides fragilis,
no clear indication to do so! and protozoa. It is the drug of choice for amoebiasis,
balantidiasis, giardiasis, Guinea worm infection, tetanus,
and trichomonal vaginitis. Resistance to it is unknown.
PENICILLINS
Alcohol should not be taken with it but otherwise has few
side effects. Use it, blindly if necessary, to all patients who
Benzylpenicillin (penicillin G) is cheap and safe.
are severely ill with an infection that might be
For streptococci and meningococci, it is the antibiotic of
caused by anaerobes, and particularly to patients with
choice. There is little point in giving very high doses.
intra-abdominal sepsis. Intravenous metronidazole
If penicillin fails to cure a patient, this will probably be
(500mg tid) is expensive, but you can achieve adequate
because the β-lactamase of penicillin resistant bacteria is
blood levels by using suppositories, or as oral tablets
destroying it, not because you are not giving enough.
inserted rectally. Like this, it is only 1/10 the price.
For an adult, 1·2g (2MU) qid is the standard dose for a
Metronidazole is one of the drugs that no surgeon should
severe infection, such as spreading hand sepsis, cellulitis
be without. Ornidazole & tinidazole are similar.
round an infected wound, gas gangrene (6.24) and tetanus.
It is also effective against anthrax, borrelia, diphtheria,
CHLORAMPHENICOL (500-1000mg qid) is cheap,
gonorrhoea, and leptospirosis. However, if drugs are
and has a broad spectrum of activity against aerobic
scarce, 0·6ggiven to 4 people is likely to do more good
Gram-ve bacilli and Gram+ve cocci. Also, if you do
than 2·4MU given to 1 person. In infants, and in patients
not have metronidazole for anaerobic infections,
with cardiac or renal disease, the sodium or potassium in
chloramphenicol is next best. It has good in vitro activity
the penicillin can cause undesirable side effects,
against anaerobes from most parts of the world.
so be aware of this.
It also enters the eye (28.3).
Its life-saving properties outweigh the very small risk of
Benzathine penicillin, or ultracillin (1·4G), is used in
aplastic anaemia. It is the drug of choice in bubonic
venereal disease (syphilis, yaws, bejel, pinta & chancroid)
plague. You cannot administer it IM. Chloramphenicol
and anthrax, but not acute surgical infections. Its use is in
with metronidazole is an excellent combination for
prophylaxis in rheumatic fever, and after splenectomy.
established or expected peritonitis (10.1). However
resistance will be common if the drug is much used in the
Procainbenzylpenicillin (3G) may be used as a once daily
community. Thiamphenicol is similar. They enhance
dosage instead of benzylpenicillin, particularly in children.
anticoagulants, anticonvulsants and the sulphonylurea
hypoglycaemics (glibenclamide etc.)
Flucloxacillin, or cloxacillin (500mg qid) are not
inactivated by penicillinases and so are very useful against
CEFALOSPORINS.
most staphylococci which are now generally resistant to
benzyl- or phenoxymethyl-penicillin (penicillin V).
There are 4 ‘generations’ of these drugs with increasing
spectrum and cost:
Ampicillin, (250-500mg qid) & amoxicillin (250mg tid)
1st: Cefradine(250-500mg qid),
are inactivated by penicillinases and so ineffective against
cefazolin (500mg qid), cefalexin (250mg qid),
staphylococci and common Gram-negative organisms such
cefadroxil (500mg bd)
as E. coli.; they are useful against chest infections & otitis
2nd: Cefaclor (250mg tid), cefprozil (500mg od),
media caused by Haem. Influenzaeand Streptococcus,
cefuroxime (750mg tid),
as well as endocarditis prophylaxis, but less so against
cefamandole (500mg qid)
urinary infections. The combination with clavulanic acid,
(less inactivated by β-lactamases than 1st generation, so
Co-amoxiclav, is effective against β-lactamase producing
cover some Gram+ve bacteria)
bacteria, and so has a broader spectrum. Amoxicillin is
3rd: Cefotaxime (1g bd), ceftazidime (1g tid),
better absorbed orally than ampicillin.
ceftriaxone (1g od), cefsulodin (1g bd).
(Use ticarcillin & piperacillin against Pseudomonas
(broader spectrum, but less good against Gram+ve
septicaemia.)
bacteria than 2nd generation)
th
4 : Cefoxitin (active against bowel flora)
MACROLIDES
They are useful to treat severe Gram-ve infection, and with
metronidazole as prophylaxis in bowel surgery.
Erythromycin (500 mg qid) is the standard alternative
Remember that 10% of penicillin-sensitive patients are
where there is penicillin allergy. It is the drug of choice for
also allergic to cefalosporins, especially if they have had
mycoplasma pneumonia, Legionnaire’s disease,
an immediate reaction to one or the other.
and chlamydial infections. It has a useful secondary effect
of stimulating gastric emptying.

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AMINOGYCOSIDES Mupirocin (2% cream) is also useful in impetigo and

secondarily staphylococcal infected fungal skin infections.
Gentamicin (80mg tid, or 240mg od) is a very valuable Pivmecillinam is active against many Gram-negative
broad spectrum antibiotic, used IV or IM, often effective bacteria, but not Pseudomonas.
against Pseudomonas. For the 'blind' treatment of a serious Aztreonam (not active against Gram+ve), imipenem with
infection, especially one due to intestinal bacteria, cilastin, meropenem, and moxalactam are powerful
use gentamicin and ampicillin or penicillin with broad-spectrum β-lactam antibiotics.
metronidazole. Gentamicin is toxic to the ears and kidneys Clindamycin is useful against staphylococci and many
if its use is prolonged; do not use it at the same time as the anaerobes, but can produce fatal pseudomembranous
diuretic frusemide. colitis.
Other costlier similar aminoglycosides are amikacin, Vancomycin and teicoplanin are used against multi-
kanamycin, netilmicin, and tobramycin; you can use resistant staphylococci, and clostridium difficile.
neomycin orally but it is too toxic; use spectinomycin
against gonorrhoea; reserve streptomycin for tuberculosis
treatment; use spiramycin against toxoplasmosis.
2.9 Methods for using antibiotics
SULPHONAMIDES
Antibiotics for treating established infection call for little
Trimethoprim (200mg bd) alone is preferable to comment, and are described in many places in these
cotrimoxazole, which is a combination of trimethoprim manuals. Antibiotics to prevent infection need to be used
and sulfamethoxazole. The latter is rather toxic and not wisely, in ways in which their benefits outweigh their
very effective. Sulphur sensitivity is common with HIV risks.
disease, and the resulting Stevens-Johnson syndrome is An operation site which was clean to start with can
often fatal. Trimethoprim is also used for pneumocystis, become contaminated with bacteria from:
toxoplasma, and isospora. (1);Outside the patient, in which case they will
probably be staphylococci. Preventing such infection is the
TETRACYCLINES purpose of the ordinary aseptic routines, and prophylactic
Tetracyclines have broad spectrum activity, but bacterial antibiotics are no substitute for it. Most surgical patients
resistance is a problem. They are the drug of choice in do not need antibiotic cover for sepsis of this kind.
chlamydia infections (donovanosis, trachoma, salpingitis, The only absolute indication for it is to cover the
urethritis, LGV), rickettsia (tick typhus), treponema implantation of prostheses, which you are unlikely to do.
(syphilis) and brucella. They also protect against malaria. (2) Inside the patient, when you operate on the colon or
They are deposited in growing bone and teeth, so don’t use the lower urinary tract, or on a woman's genital tract.
them in children <12yrs, or pregnant and breast-feeding When you use antibiotics prophylactically, aim to provide
women. Absorption of doxycycline (100mg bd), unlike a concentration in the blood that will kill any bacteria
tetracycline (250mg qid), is not decreased in effect by introduced into the wound at the time of the operation.
milk, antacids or calcium, iron and magnesium salts, To minimize the risk of peritonitis, it is important to
and is safe in renal disease. protect against enterobacteria (mostly E. coli), as well as
aerobic and anaerobic streptococci, bacterioides, and
QUINOLONES clostridia. A single broad spectrum antibiotic with good
Ciprofloxacin (500mg bd) is active against Gram-ve & tissue penetration and long half-life is ideal.
+ve bacteria (but not usually Strep pneumoniae and Use the antibiotics IV preoperatively (especially with the
Enterococcus faecalis) and is particularly active against premedication or the start of surgery), so that high
salmonella, shigella, campylobacter, neisseriaand concentrations are reached in the wound at the time of
pseudomonas, and chlamydia. surgery. Starting them a day or more before the operation,
Nalidixic Acid (1g qid), norfloxacin (400mg bd), or continuing them unnecessarily afterwards, promotes the
ofloxacin, enoxacin, cinoxacin, pefloxacin, sparfloxacin selection of resistant organisms and the risk of side-effects,
are useful in urinary-tract infections. and has been shown to confer no extra benefit.
Do not use them in epileptics, for children, in pregnancy,
and breast-feeding. They enhance the effect of If you forgot to give the antibiotic before the operation,
anticoagulants. it is still worthwhile to do so before closing the skin, but
not afterwards. (That would be like washing your dirty
OTHERS hands after eating a meal!)
Nitrofurantoin (50mqid) is useful in uncomplicated There are several unacceptable methods:
urinary tract infection. (1) Do not put topical antibiotics into a patient's wound.
Fusidic acid (500mg tid) should be specifically reserved (2) Do not use them in the hope of 'sterilizing the colon'.
for penicillin-resistant staphylococcal osteomyelitis; (3);Do not use antibiotics for longer than a specified
as a cream (2%), it is useful for impetigo, but should not period in the vain hope that infection or fever might finally
be used for simple skin ulcers, because of the problem of be controlled.
resistance.

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As to the antibiotics to use, you will see from the list of ONLY A FEW HIGH RISK PATIENTS NEED
indications below that, if chloramphenicol is not PROPHYLACTIC ANTIBIOTICS
much used in the community, chloramphenicol with
metronidazole is likely to be the most cost-effective “We may look back on the antibiotic era as a passing
combination. Otherwise, use cefradine (or some other phase, an age in which a great natural resource was
cephalosporin) with metronidazole, which are much better squandered.”
than penicillin and streptomycin.
Always differentiate prophylaxis from treatment.
Using your more expensive antibiotics in life-threatening 2.10 When prevention fails: wound infection
sepsis makes more sense than wasting them in dubious
prophylaxis. If you are treating septicaemia, aim to If a wound discharges pus, the aseptic routines described
continue the antibiotic regime until the illness is under earlier in this chapter have broken down. Although this is
control (usually 5-7days). Once a patient can take drugs not the only cause of a wound infection, it is the most
orally, there is usually no longer any need to give them IV. unnecessary one.

THE DOSE AND THE TIMING ARE CRITICAL: Keep a record of your wound infections. They are most
MAKE SURE THERE ARE ADEQUATE LEVELS likely to occur if:
AT THE TIME OF SURGERY (1);You are operating for some infective condition, such as
acute appendicitis.
PERIOPERATIVE PROPHYLAXIS: INDICATIONS. (2) The operation is long and difficult.
(3);You leave dead tissues, foreign bodies, dirt, or clot, or
(1) Peritonitis (but antibiotic use here is likely to be an excessive number of sutures (especially non-
therapeutic rather than prophylactic) absorbable) in the wound.
(2) Operations likely to contaminate the peritoneal cavity, (4) You create dead tissue by operating clumsily.
especially with spillage from the colon, appendix, (5) You do an unnecessary un-clean procedure at the same
bile duct or stomach. time as the clean surgery.
(3) Operations on the urinary tract when the urine is (6);You close a wound by immediate primary closure,
already contaminated, including bouginage, when delayed primary closure would been have been
cystoscopy, and prostatectomy. wiser.
(4) Hysterectomy. (7);You leave IV cannulae, chest drains or other drains in
(5) Emergency Caesarean section. longer than necessary.
(6) Intracranial explorations.
(7) Open fracture surgery, and amputations. SURGICAL SEPSIS.
(8) Re-opening haematomas. (1) A theatre had extractor fans installed, but the only inlets for fresh air
(9) Splenectomy. were under the doors, so that dust from the corridor was drawn into the
theatre continually. Only when three patients had died of tetanus was the
(10) Dental or oral surgery with known heart valve disease. flow of the fans reversed.
LESSON Keep dust out of the theatre.
CAUTION! (2) In a certain teaching hospital, there were two minor theatres in which
Gentamicin and other aminoglycosides may seriously many septic operations were done. On 2 mornings a week the same
equipment was used for a list of circumcisions. One circumcised child
prolong the action of long-acting (non-depolarizing) acquired erysipelas which spread from the umbilicus to the toes and
relaxants, and may prevent the establishment of killed him.
spontaneous ventilation. Avoid them unless your LESSON Where possible do not do clean cases in a theatre which
anaesthetist is experienced. normally does septic ones.
(3) An eminent professor electively resected an appendix at the same time
N.B. Prophylactic antibiotics will probably not cover as cholecystectomy. The patient developed an anaerobic wound infection
the perioperative risk of respiratory infections. and later a faecal fistula.
Physiotherapy is far more likely to be effective, both pre- LESSON Do not do unnecessary procedures which increase the risk of
and post-operatively. infection.
(4) Hamilton Bailey, subsequently a distinguished surgeon, but then a
registrar in the 1930’s, was deputizing for the chief. Having done an
CONTRAINDICATIONS. Antibiotics are not needed for: elective list which began at 1.30p.m. he insisted on continuing with a
(1);Already well-localized infections. non-stop flood of emergencies which continued rolling in all the evening.
(2);Clean category 1 operations (hernia repair, ovarian At 3 a.m. the following morning, 'dead on the feet', he pricked himself
when operating on a patient with streptococcal peritonitis. Bailey insisted
cystectomy, etc) that the finger be amputated, and survived. The patient died.
(3) Burns (initial treatment) LESSON Accidents, including those which increase the risk of sepsis,
(4) Tracheostomy, intercostal drainage, simple lacerations. hepatitis and HIV transmission, are particularly likely if you are
overtired.
If you are using a tourniquet, time the injection to provide
If >5% of your clean cases become infected, something
the maximum concentration about the time that you
has gone wrong. Prophylactic antibiotics are not the
release it, so that the clot which forms in the wound will be
answer! The chances are that the aseptic technique (2.3)
heavily loaded with drug.
is not being followed, or you are making the errors 3, 4,
and 5 above.

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THE PREVENTION OF WOUND INFECTIONS If you are successful, the wound will heal spontaneously.
AUTOCLAVING. Otherwise, you will have to open around the sinus and
(1);Check that your autoclave does reach 1 kg/cm2 (2.4), extract the foreign material.
that the air is being discharged, and that the holding time is
being maintained. If a growth develops from the wound, this is a pyogenic
(2);Check that the drums are not being overpacked, granuloma (34.4): excise it and check for HIV disease.
that they are labelled after autoclaving, and that the label
includes the date.

THEATRE DISCIPLINE. Check that you and all your

staff are following all the aseptic disciplines (2.3)
carefully. If you set an example, your staff will follow.
Check that:
(1);the theatre table and especially the plastic cover on its
mattress, are being properly cleaned,
(2);there is no infected member of staff: check for nasal
and skin carriers of staphylococcus especially if an
outbreak of hospital infections occurs. Examine yourself.
Are you committing errors 3, 4, or 5 above? Fig. 2-10 CONSIDER THE TRAFFIC.
Wounds are less likely to become infected, if the theatre is not used as
a storeroom, and if there is the minimum of traffic in and out of it. So
THE TREATMENT OF WOUND INFECTIONS remove the teacups and cartons, the bicycle, the umbrella, and that
Sedate the patient with morphine, pethidine, diazepam or coat! Close the doors! Drawn by Nette de Glanville.
ketamine, if necessary. In infected sutured wounds the pus
usually tracks the whole length of the subcutaneous
tissues. So remove all sutures and convert the wound into
an open gutter. If possible, send a swab for culture.
Clean the wound; use hydrogen peroxide if it is smelly. 2.11 Post-operative pain control
Establish free drainage, especially in the depths of the
wound, keep it open so that it can heal from the bottom, Your reputation will grow enormously if your patients do
and pack the wound daily with antiseptic dressings. not suffer any discomfort after surgery; unfortunately
Either allow it to granulate or close it by secondary suture much good pain management is hindered by myths, fear or
when it is 100% clean. If sepsis is troublesome, consider ignorance. Unrelieved pain has significant effects
the use of pure ghee (the clear liquid skimmed off the top on a patient’s physiology as well as psychology.
of slowly heated butter) and pure honey in a ratio 1:2, Pain scoring systems are very useful in establishing an
sugar, pawpaw, or even sterile maggots. objective measurement of analgesia:
VERBAL: NONE-MILD-MODERATE-SEVERE-EXTREME
Antibiotics are only indicated if there is spreading
NUMERICAL:INTENSITY 0 (no pain) – 10 (worst pain)
infection (cellulitis) or septicaemia. There is no rôle for
topical antibiotics. If you have many septic wounds to deal VISUAL: INTENSITY LINE ☻(no pain) - † (want to die)
with, or not enough staff or dressing materials, N.B. The intensity of pain is what the patient says it is!
leave the wounds open and exposed to the sun for as long
as possible. Check that there is no indiscriminate or The visual system is most useful in children. Since many
undisciplined use of antibiotics. patients after major surgery cannot speak well, you should
have these scoring charts on a board ready to show them.
If there is oedema and a brownish discharge comes
from the wound, and the patient toxic and apathetic, Don’t ignore the patient who complains of pain: it may be
suspect gas gangrene (6.24); if there are spreading a sign of a serious complication.
purplish discolouration and signs of subcutaneous
necrosis, suspect necrotizing fasciitis (6.23). In both The aim should be to prevent pain: a patient should wake
cases, immediate extensive debridement is necessary to up after surgery with no pain, and be encouraged to ask for
save life. analgesia as soon as pain develops.

If a wound fails to heal, think of diabetes mellitus, Combinations of analgesic drugs and of routes of delivery
HIV (5.6), anaemia, malnutrition, the presence of cancer give the best results. You can provide much pain relief by
or a foreign body. putting large volumes of low concentration long-acting
local anaesthetic (bupivacaine) into the wound at the end
If a sinus develops from a wound, suspect an infected of the operation; do not inject it into the surrounding
buried non-absorbable suture knot (a stitch sinus); sterilize tissues if the wound is infected: you can then just drip it
a crochet needle and use this to try to hook the knot out of into the wound and leave it for 1min to get absorbed.
the wound.

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The sad reality is that in present practice many patients If you know that an operation will give considerable pain,
wake up with pain, shout for help and are shouted at in prescribe regular analgesia for the first 2-3days, not ‘PRN’
turn, until eventually, they are given a large IM dose of (which stands for pro re nata = as required, but often in
opioid. They then go to sleep again. Later, when the practice implies ‘presumably rarely needed’)
analgesic effect wears off, the cycle repeats itself.
This is not only unsatisfactory from the point of view of For MILD PAIN, paracetamol is ideal. It can be given as a
needless suffering but is often the cause of postoperative syrup for children or those who have difficulty
complications: atelectasis, deep vein thrombosis, vomiting, swallowing.
anorexia, constipation, dehydration, urinary retention,
and it also prevents people from getting out of bed. Trans-cutaneous electrical nerve stimulation, and neuro-
acupuncture can give added relief if you have these
For SEVERE PAIN, morphine is preferable to pethidine, facilities.
because it produces less respiratory depression,
less nausea, and is less of a cerebral irritant.
It also lasts longer. (Pethidine needs to be repeatedly given 2.12 Records
3hrly to be effective)

Because these are controlled drugs, nurses will often only Keep meticulous records of operations performed: train the
give them at standard drug dosage times. Challenge your theatre staff to fill in the book immediately and keep these
local regulations if these inhibit patients getting proper records accurately. Bad records are almost as good as no
pain relief. Try to get solutions of oral morphine made records at all! You should have all the following
locally. This should not cost >1c.(US)/mg! Do not use information in the theatre book (which obviously should
injectable opioids SC or IM but always IV, injecting be fairly large, and preferably hard-backed):
slowly: this way relief will be immediate and the dose
received will be less. Small, frequent IV opioids will DATE
prevent pain and it will be possible to switch to the oral or OPERATION NUMBER
rectal route within 24hrs in most cases. Apart from being PATIENT’S NAME
PATIENT’S AGE/SEX
much more effective if given IV, either as boluses or better
PATIENT’S HOSPITAL NUMBER
as an IV infusion, they are safer given this way as you DIAGNOSIS
thereby must watch the patient’s response. OPERATION PERFORMED
EMERGENCY/ELECTIVE
SURGEON
A calculated IV infusion of opioid is not dangerous!
ASSISTANT(S)
(If the IV infusion has accidentally run in fast with all of ANAESTHETIST
its added 10mg of morphine, simply omit the dose with the ANAESTHETIC USED
next litre of IV fluid.) Arrange the infusion in theatre with SCRUB SISTER
TIME STARTED & TIME FINISHED
the co-operation of the anaesthetist.
COMPLICATIONS
In children, tilidine oral drops (x1 per year of age up to 10) HISTOLOGY/PUS SWAB RESULT
is very useful indeed.
Keep your book neat: if necessary fill in details initially in
Ketamine gives good post-operative pain relief; pencil. Keep to the columns drawn in the book.
its hallucinatory effects are diminished by giving diazepam It is important to use the same nomenclature throughout,
before the operation, i.e. with the ketamine. e.g. 12 Feb 2004 for the date (and then not use 12/02/04
or, worse, 02/12/04), and particularly consistency in
Remember that opioids occasionally cause hyperalgesia abbreviations (e.g. I&D for incision & drainage, MUA for
(especially if used for non-malignant causes); but beware manipulation under anaesthetic etc). Try to keep names
of the patient with chronic pain who regularly refuses consistent, using the family name first in CAPITALS and
opioids (he probably needs them) and the patient with then the first (and second) names. The more detail you can
aberrant behaviour who demands them (he does not need put, the better will be your records, and your ability to do
them!) research.

For MODERATE PAIN, the choice is paracematol-with- Under ‘Diagnosis’ be sure to put the correct diagnosis
codeine and/or a non-steroidal anti-inflammatory drug. (which may differ from the pre-operative diagnosis).
The latter have considerable side-effects: peptic ulceration,
renal impairment, and coagulation problems. They can be Under ‘Anaesthetic Used’, you should put at least GA for
given rectally if a patient is not taking in orally. general anaesthetic, Sedation, or LA for local anaesthetic.
The evidence that they are any more effective than You could put Thio/O2/N2O if using thiopentone, oxygen
paracetamol-with-codeine is not convincing, but it is and nitrous oxide, or Ket if using ketamine, but the more
always best to ask the patient which drug he finds best! detail in the records the more diligence is required in
keeping them. Often there are no records at all which is a
disastrous and unacceptable state of affairs.

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You should come back and check the theatre records,

in case details are filled in incorrectly. Get your nurses to
write details in pencil for you to correct, if necessary, later.
Make a particular note of complications. This not only
includes immediate problems (like bleeding or a death on
the table), but later ones such as wound infections.

If you direct laboratory results of histology and pus swabs

to theatre so that they are recorded there in the book,
they are much less likely to get lost and can be much more
easily referred to.

Some details are optional, e.g. indication for operation,

grade of operation (minor, intermediate, or major),
and type of procedure (endoscopy, orthopaedic, ENT etc).
Grade of operation is notoriously subjective; we suggest
that if you use any, to use that described in the appendices.

You should keep a separate book for deliveries of babies,

and decide whether you should enter operative deliveries
with the other operations, or separately.
It doesn’t matter as long as they are properly recorded!

If you keep good records, you will be able to highlight

problems when things go wrong. You can keep an audit on
how much work you are doing, what your requirements
are likely to be, and therefore your costs. You will have a
valuable resource for research. This is very important.
You will also derive satisfaction from a job well done,
and leave a functioning system in place for your successor.

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A pressure dressing is only really effective on the head,

3 The control of hand or foot; otherwise on a limb it acts as a venous
tourniquet, which may increase bleeding!
On the chest it will interfere with respiration, and it is
bleeding useless on the outside of the abdomen.

Inside the abdomen, remember that pinching the base of

3.1 Assisting natural mechanisms the mesentery between the fingers of one hand will
occlude its blood supply, so you can buy time if there is
significant haemorrhage from the bowel or mesentery
Most surgical intervention will result in some sort of itself.
bleeding. This can also happen from an injury.
The body has excellent mechanisms for controlling You can also control bleeding from the liver by
bleeding, so that your task is mostly supportive. The main compressing the vessels in the free edge of the lesser
mechanisms are the cascade of enzymatic reactions which omentum (the Pringle manoeuvre, 15.8), or from the uterus
make the blood clot, and the ability of the muscular walls or lower abdomen by pressing the aorta against the spine
of the arteries to contract. (22.11). This is most effective if you go through the
avascular area of the lesser omentum after pulling the
If you fail to control bleeding adequately a patient may stomach downwards. Alternatively, if the bleeding is
die, so take note of the amount of blood he loses. higher up, you will need to open the space between both
The loss of a given volume of blood is more serious in a crura of the diaphragm to expose the abdominal part of the
child (3-1) and much more serious in a baby, than it is in a thoracic aorta. Clearly, if you can get a vascular clamp
fit adult, who can usually lose 1l without the need to onto the aorta, this is better than your fingers,
replace it by blood. A loss of >20% the blood volume is but don’t give up if you do not have vascular instruments!
critical: a child has a total of 75ml/kg of blood. Just press and wait.

The most generally useful ways of controlling bleeding is Packing.

pressure, but there are also special methods for A variation of this method is to pack a wound and to
particular parts of the body, such as the scalp and the dura, remove the pack ≤24hrs later, as with hepatic bleeding,
the bowel (11.3) and the liver. bleeding from the pelvis, or after a sequestrectomy (7.5).
Note that packing does not mean stuffing gauze
Most importantly, don’t panic! Have a plan of action, indiscriminately into a cavity, but laying it carefully and
starting with the simplest methods, and, if these don’t methodically to obliterate a space if the packing is done
work, progress to more complicated techniques. inside a cavity, or laying gauze outside a solid organ on
Stop to reassess the situation: don’t fumble around: both sides like a sandwich, and wedging this firmly. If the
you will lose valuable time and achieve nothing! Don’t try packs become soaked at the edges, remove them gently
to get definitive control of bleeding from the outset: aim and pack more tightly.
for temporary control initially. This should be quick,
effective and not cause more damage to the patient. Ligature: a haemostat (artery forceps) can be used to
grasp a bleeding vessel, particularly an artery which is
These are the methods you can use: spurting blood at you. If the vessel is a large one
Pressure is the simplest and most valuable way to control which you’ll need to repair, use vascular clamps or
bleeding. When you press on tissue, the walls of its vessels gauze-covered forceps. Be sure you can see the vessel.
come together, and where their edges are cut, thrombus You can then tie it. Get an assistant to hold the forceps
will start to form. When you release the pressure you will and release it when your tie is secure. If you cannot see the
probably find that bleeding has stopped, or that only the bleeding point, use a suture on a large needle and pass this
arteries will continue to spurt at you, and these you can tie through a good firm amount of tissue adjacent, and pull the
off. Press with a gauze pack. If pressure is to succeed, suture towards you. This may control the bleeding,
you must press for long enough: this is normally at least at least partially. Pass the suture in a parallel direction
5mins by the clock, which is one reason why every theatre below the first point and so tie it as a figure-of-8 (4.8).
should have a clock. If the tissue behind the bleeding area Sometimes this does not fully control bleeding,
is firm, as when you press a bleeding scalp against the so take 2 more bites at right angles (the ‘clover’ suture).
skull, pressure is even more effective. Likewise a finger in
a groin wound, pressing against the hip joint, is extremely Inflating a balloon in an orifice is a very useful
effective. procedure, especially in bleeding from the neck,
For bleeding from the finger, do not try anything else! liver or uterus. Pressure in a confined space is very
Note that putting on more and more dressings effective at stopping bleeding.
(so increasing the applied area) dissipates the pressure
(which is force per unit area), so their effectiveness is Repairing a bleeding vessel, either by closing a laceration
reduced. If a wound dressing is soaked, remove it, in its wall, or by making an end-to-end anastomosis will be
and apply pressure directly to the bleeding point! necessary to control haemorrhage in a major vessel.
This may save a limb.

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You may be able to control massive bleeding from a large Bone wax packed into the bleeding edge of the skull into
vessel by inserting a balloon catheter into its lumen, the diploe, or into the marrow of a bone, will stop the
and inflating the balloon. bleeding if it is not too aggressive.
Alternatively, occasionally you can put a tube shunt
between the widely separated ends of a large important Adrenaline, already added 1:100,000 to lidocaine solution
artery, fixing these in place with tape. or to saline, used to infiltrate the tissues, will minimise
Get proximal control by formally exposing the vessel high capillary and venous bleeding, e.g. during the repair of a
above the bleeding point. This will only be necessary on vesico-vaginal fistula (21.18), in thyroidectomy (25.7) or
unusual and desperate occasions. On rare occasions you cleft lip repair (31.7). You can also use a pack soaked with
may have to tie off the artery despite the consequences of 1mg adrenaline in a bleeding nose (29.7), or on a bleeding
distal ischaemia. tooth socket (31.3).
Never use adrenaline in the penis, or the distal parts of a
limb such as a finger or toe, or in an IV forearm block,
because it may constrict the vessels so much that the part
becomes gangrenous.

Hydrogen Peroxide (6%, 20 vols) is useful not only to

clean a wound infected with anaerobic organisms, but will
also slow bleeding.

Assisting blood clotting is important. When you have

transfused >5 units of blood, the citrate in it will lower the
calcium concentration in the blood and prevent it clotting.
So do not forget to add 10ml of 10% calcium gluconate IV
after every 4th unit of blood. When blood fails to clot,
you can use fresh blood, but this may be impractical.
You can store fibrinogen for such a purpose; fresh frozen
plasma (FFP) is ideal but often pooled from several blood
donors, and so its risks of HIV transmission are
significantly greater than blood.

Tranexamic acid (cyklokapron) 1g IV over 10mins and

then 1g over 8hrs or as 20mg/kg tid is a useful adjunct,
without these problems.

Blood may fail to clot in the presence of liver disease,

Vitamin C deficiency, or if the patient has taken excess
warfarin or its effect is potentiated by other medicines.
In this case, use Vitamin K 10mg orally, but take note it
takes 48 hours to be effective! Remember also that aspirin
as well as garlic have an anticoagulant effect, and
excessive use by patients may cause bleeding problems!

Raising the bleeding part will lower the pressure in its

veins, and so minimize bleeding. This is valuable if there
is bleeding from a limb, or the venous sinuses of the brain
(a rare and difficult emergency), when the level of the
head in relation to the rest of the body is critically
Fig. 3-1 BLOOD LOSS IN ADULTS AND CHILDREN.
important. But there is a risk of air embolism if a rigid
A,B, when you operate on a child, make an accurate 'blood balance vascular channel, such as a sinus, is raised above the level
sheet'. In a major operation measure the blood lost by weighing the of the heart.
blood-soaked swabs on a balance. Replace blood lost with an equal
volume of blood as soon as possible. This should be HIV and HBV
free. C, a fit adult, such as a mother having a Caesarean section, can
A proximal pneumatic tourniquet will control bleeding
tolerate a blood loss of up to 1l or even 1·5l, before you need to from the distal part of a limb, especially before or during
transfuse blood, rather than Ringer's lactate or saline. an operation (3.4). For many operations this is essential,
You can usually measure the blood lost in a suction bottle. because it produces a bloodless field. Using a tourniquet in
the trauma situation is useful to buy you time whilst you
Haemostatic gauze will eventually stop bleeding from the are organizing theatre. Make sure you note how long the
oozing cut surface of the liver, or the surface of the brain. tourniquet is applied! A tourniquet round the cervix or
Unlike ordinary gauze it is slowly absorbed. uterus (22.11) can control uterine bleeding.
It is expensive and rarely indicated. A substitute is to cut a
piece of muscle, hammer it flat, and use this.

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The common mistakes are: Spencer Wells are general purpose haemostats; Crile’s are medium-sized
and more robust than Halsted’s, which are some of the finest and most
(1) To panic when there is severe bleeding.
delicate instruments and must be used with care. Blalock (bulldog)
(2) Not to apply pressure when this is indicated, and not to clamps are non-crushing clamps to stop blood spilling from a vessel
apply it for long enough, or to apply it diffusely through whilst it is being repaired. Mayo’s pins keep forceps together in bunches
more and more rolls of cotton wool and bandage. during sterilizing.
(3);To grasp wildly with a haemostat in a pool of blood,
Spencer Wells, straight, box joint, (a) 200mm, (b) 150mm.
to fail to grasp the bleeding vessel, and perhaps to injure Spencer Wells, curved, box joint,
some important structure. (a) 230mm, (b) 200mm, (c) 150mm, (d) 125mm, curved.
(4) Not to apply the special methods for special sites. Crile's, straight, box joint, 140mm.
(5) To cross-match blood too late. Crile’s curved, box joint,
Halsted's, ultrafine, mosquito, haemostatic, straight, box joint, 120 mm.
Halsted’s, ultrafine, mosquito, haemostatic, curved, box joint, 120mm.
A STORY ABOUT BLEEDING. A young trainee surgeon was excited to
Kocher's, straight, box joint, 200mm.
be able to assist the professor at an operation for a leaking aortic
Kocher’s curved, box joint, 200mm.
aneurysm. Predictably, there was quite a lot of bleeding seen when he
Blalock artery clamps (various sizes)
released the big aortic clamps. In fact he hadn’t seen so much blood in the
abdomen outside of the trauma situation, where there was always frantic
activity to stem the bleeding. When the professor had sutured in the graft,
there was considerable oozing from the suture lines. He simply put in a
big pack and asked the assistant to press gently, but firmly, till he
returned, and went off to have a cup of tea! Petrified, the trainee hardly
dared breathe, let alone move. When the professor came back 10mins
later well refreshed, he re-scrubbed, and removed the pack; the operative
field was perfectly dry.
LESSONS When you control bleeding by pressure or with a pack
sufficient time (≥5mins by the clock) is all important.

HAEMOSTATS

Fig 3-3 MORE FORCEPS.

Lahey’s are similar to Crile’s; Mixter’s have a more angled curve on
their ends. The Mosquito forceps are fine and useful to hold threads.
Pean’s are long straight forceps. Kocher’s are large haemostats with
a tooth at the end of their jaws, for use on a wide vascular pedicle
when an ordinary haemostat may slip.

3.2 Arterial bleeding

If you can see a bleeding vessel, you can grasp it with a

haemostat (locking or artery forceps), which is one of the
great inventions of surgery. Tie all larger vessels,
either immediately or later. Small vessels, especially those
in the skin, seldom need tying. When you remove a
haemostat ≥5mins later, you will probably find that
bleeding will have stopped. You can encourage it to stop
Fig 3-2 HAEMOSTATS.
If you can see a bleeding vessel, you can usually grasp it with these by twisting the haemostat before you remove it, or if the
locking forceps, which are one of the great inventions of surgery. bite of tissue is too large to twist, you can release the jaws
Do not use them as towel clips, because they will then no longer close and quickly pinch them together again a few times before
finely enough for blood vessels. you remove them.

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Either of these methods will encourage the blood in the

vessel to clot and will minimize bleeding, so that fewer
vessels need tying. Haemostats can be large or small,
straight, or curved, so that they rest over the edge of the
wound. Haemostats have some disadvantages.
Each time you tie off a bleeding vessel you leave some
crushed tissue and some suture material in the wound.
If this is excessive, it can encourage delayed healing or
infection later.
The tips of haemostats, especially small ones, must meet
accurately, so good quality instruments are important.
Never misuse haemostats as towel-clips! Box joints are
worth the extra expense. Order them in sets of 6
(you can hardly have too many) because they will enable
you to make up several sets (4.12).
It is best to cut skin boldly, which produces less bleeding,
than tentatively and timidly which produces a sawing-type
of action on the vessels.

TO TIE AN ARTERY use the following materials in this

order of preference: long-acting absorbable, linen thread,
cotton thread, or silk. Do not use catgut for larger and
more important vessels: it slips off too easily and may be
reabsorbed too quickly. Grasp the bleeding artery with a
haemostat. Either:
(1) Tie it with one firm reef knot.
(2);Tie it with a surgeon's knot (4.8) followed by 2 to 3
more throws.
(3);Transfix it, tie it with a reef knot, then pass one ligature
through it with a needle, and tie it with another reef knot.
Fig. 3-4 TYING ARTERIES.
This is the method for critically important vessels, A, do not leave too long an end; this will leave unnecessary dead tissue
such as those of the renal pedicle. For even more security, in the wound. B, to free a vessel buried in tissue, insert Mixter
tie it proximal to a branch, and then cut it distal to this. forceps and spread the tissues. C, if possible, put the ligature
proximal to a branch. D, tie the artery and insert a transfixion
ligature; the needle is going through the vessel and its distal end is
If it is a critically important vessel, ask yourself about to be cut off. E, completed ligature. F1, hold a length of suture
if what you’ve done is enough. If not, do it again: material in a curved haemostat. F2, pass another curved haemostat
put a 2nd tie in a separate groove. under the vessel to grasp the suture material. F3, pull the suture
material under the vessel. G, using an aneurysm needle.
If there is a long length of vessel distal to your tie,
shorten it, so as not to leave too much dead tissue in the TO GET A LIGATURE ROUND AN ARTERY,
wound, but do not shorten it too much! either use an aneurysm needle, or pass a curved haemostat
under it, and ask your assistant to pass into your other
If other methods of controlling severe arterial bleeding hand a curved haemostat with a ligature 'bowstrung' across
have failed, you may, very occasionally, have to expose it (3-4F). This is useful in 'deep' surgery. You may be able
and tie a major vessel, such as the external carotid or the to use ligaclips (4.10).
subclavian artery. Use linen, cotton thread, or silk;
do not divide the vessel after you have tied it, as it may
recannulate. 3.3 Diathermy

TO CONTROL BLEEDING FROM A LARGE Heat causes coagulation of blood in vessels; this has been
PEDICLE, such as that of the spleen or uterus, do not try known for centuries. In order for an electric current to
to use a single ligature. Control of the vessels will be safer provide sufficient heat on a small area but without causing
if you take one or more bites of the pedicle and tie them muscle spasm and cardiac dysrhythmia, diathermy uses
separately. radiofrequency currents of 0·5-1·5MHz.
TO CONTROL A DIFFICULT BLEEDING ARTERY,
try to get into the correct tissue plane. First find the artery In monopolar diathermy, there is a high current density
by feeling for pulsation. Push the points of a fine ensured at the point of contact with the active electrode at
haemostat into the connective tissue around it and separate the diathermy probe tip but the current is then dissipated in
them to open up a plane (3-4B). Gradually develop this a large volume of tissue through a large surface area
plane until you can see the artery you are looking for. ‘indifferent’ electrode, usually a plate placed under the
In this way you will avoid tying some important nerve in buttock (3-5A). You must make sure this contact is good
the ligature. and uniform, otherwise a burn may result.

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Make sure the wire connections in the instrument are Do not use diathermy on the groin if the scrotum is not
sound, because poor contacts will increase the heat and so in contact with the rest of the body: you might cause
cause burns. Usually you will pick up a blood vessel with coagulation in the testicular vessels, especially if you lift
dissecting forceps, and touch the forceps with the the scrotum up in your hand.
diathermy tip. As metal is a good conductor of current,
little heat is generated in its passage through the forceps. Do not use diathermy in an amputation for an ischaemic
Make sure though that your gloves have no holes, leg (35.3): you will increase tissue necrosis.
otherwise you may experience an electric shock and burn
when the metal forceps comes in contact with your own Do not use diathermy on large blood vessels:
skin! tie them instead.

In bipolar diathermy, the current passes between two If the patient has a cardiac pacemaker, the diathermy
point electrodes placed across the vessel to be coagulated. current may affect this; so place the indifferent electrode
In this way a very high current density, and so much heat, far away, or use bipolar diathermy.
is produced over a very small volume of tissue, with
virtually no heat generated elsewhere (3-5B). Do not use diathermy in the presence of inflammable
Bipolar diathermy only works with low currents, and is anaesthetic agents, e.g. ether, and take care if you use
therefore most suitable for small blood vessels, and fine spirit-based skin cleansing preparations that the fluid does
surgical procedures. not pool: serious burns may result.

Do not use of diathermy on obstructed bowel:

it may detonate if methane gas has accumulated inside!

Reduce the current of the diathermy inside the mouth

in operations under GA, because nitrous oxide as well as
oxygen supports combustion, and its concentration is
always higher there than elsewhere.

3.4 Bloodless limb operations

One of the great advantages of operating on a limb is that

you can use a tourniquet to prevent bleeding. This will
save blood and enable you to see the tissues more clearly.
You can use any of these:

A special pneumatic tourniquet which resembles the cuff

of a sphygmomanometer. The pressure at which a
Fig. 3-5 DIATHERMY.
tourniquet is applied is important; this is more easily
A, monopolar diathermy produces high current density at the active controlled pneumatically, so a pneumatic tourniquet is
electrode dissipated through the body tissues through the much the best. Also you can, if necessary, let it down
‘indifferent’ electrode with resulting low current density. B, bipolar rapidly during an operation to perfuse the tissues, or to
diathermy produces high current density across insulated diathermy
forceps tips. After Sear JW, Rosewarne F. Anaesthesia for Surgeons,
find arteries that need tying. The Conn improved
Oxford Textbook of Surgery, OUP 1994 p.83 Fig.2,3. pneumatic tourniquet with dial, complete in a case, in adult
& child sizes is one of the most useful surgical appliances,
Radiofrequency generators produce different waveforms to and is almost essential; alas, few hospitals have them.
give a coagulating (repetitive bursts of current cycles) or a
cutting (continuous current) pattern; these are blended An Esmarch bandage is a strip of red rubber.
together for endoscopic resection (e.g. in prostatectomy). It is satisfactory, provided:
(1);You spread it out carefully over an encircling cotton
DANGERS OF DIATHERMY wool pad.
If you touch the skin or vessels very close to the skin (2) You do not put it on too tight, especially on a thin limb.
edge with the diathermy electrode, you will produce a (You can make one from an inner tube of a motorcycle
skin burn. If small, it is best to excise this, especially if it tyre (3-7): the tube from an ordinary car tyre is too thick)
is on the edge of a wound. Otherwise, treat it like any
other skin burn wound. A reliable sphygmomanometer. You may not have a
special pneumatic tourniquet, so this is probably what you
Do not use diathermy on the penis: you may cause will have to use. A tourniquet will prevent blood entering a
thrombosis in the corpora unless you use bipolar limb, but it will not remove blood which was already there
diathermy. when you applied it.

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Remove this blood in 2 ways: SITES FOR APPLYING A TOURNIQUET

(1);Raise the limb for ≥1min to help the blood to drain There are only 4 of these:
before applying the tourniquet. This is the only safe thing (1),The middle of the upper arm (3-6D).
to do if there is sepsis. It will leave a little blood in the (2);The finger (3-6F). Use part of a rubber glove.
vessels, which can be an advantage, because you can more This is only safe for a short procedure, such as draining a
easily see where they are. pulp infection.
(2);Wind an Esmarch bandage round the limb from its (3) The upper thigh, a hand's breadth below the groin in an
distal to its proximal end to squeeze out the blood. adult (3-6E). At this point the femoral artery lies close to
Then apply a pneumatic tourniquet (or a sphygmo- the femur and is easily compressed.
manometer) round the base of the limb to stop blood (4) The cervix (23.7)
entering it. Finally, remove the Esmarch bandage.
This will provide an almost totally bloodless field,
but is only safe if there is no sepsis, which would then be
spread proximally.
N.B. A tourniquet has disadvantages:
(1) If you apply too much pressure for too long over too
narrow an area, you may injure the nerves to the limb,
and cause a paresis; this is usually only temporary,
but it may be permanent. A transient radial nerve palsy is
common, even if you apply a tourniquet correctly.
(2) If you forget to take a tourniquet off, so that it is left
on for ≥6hrs, Volkmann's ischaemic contracture,
myoglobinaemia, or gangrene may follow. This happens
more easily if there is arterial disease.
(3) If a tourniquet is too loose, it may obstruct only the
veins, and increase bleeding.
So apply a tourniquet carefully; record the time when you
applied it, and do not leave it on too long.
N.B. Never use a Samway's tourniquet. (This is a rubber
tube with a hook at one end: it too easily injures the tissues
beneath it.)

IF YOU APPLIED A TOURNIQUET, IT IS YOUR

RESPONSIBILITY TO REMOVE IT

TOURNIQUETS
INDICATIONS.
(1) Wound toilet in an injured limb, particularly if this has
to be followed by repair of the vessels, nerves,
and tendons.
(2);Any hand operation, other than a very small one.
Hand injuries, and hand sepsis.
(3) The exploration and drainage of bones and joints, when
this is anatomically possible, as in the lower humerus,
the elbow and parts distal, or the lower femur, the knee,
and parts distal.

CONTRAINDICATIONS.
(1) The SS and CS varieties of sickle cell disease, but not Fig. 3-6 TOURNIQUETS.
AS heterozygotes. A, do not use Samway's tourniquet, as you may damage the tissues.
(2) Ischaemia due to arterial disease. B, a pneumatic tourniquet is much the best. C, the Esmarch bandage
is a roll of red rubber. D, site to apply it in the arm. E, site in the leg.
F, use a rubber catheter as a finger tourniquet. G & H, when you
ANAESTHESIA. A tourniquet is painful and a conscious apply a tourniquet, take the time and record it. I, If you want to
patient will not usually tolerate one for >5mins. exsanguinate the arm, raise it and then apply Esmarch bandage,
You will therefore need either GA or regional anaesthesia starting at the hand. J, inflate the pneumatic tourniquet, then
unwind the bandage, starting proximally in the limb. K, you can use
in most cases. an Esmarch bandage as a tourniquet.
HANK (42yrs) was to have a bunion removed. The junior resident was
asked to apply an Esmarch tourniquet. He had never applied one before, N.B. Do not exsanguinate a septic limb or where there
so he just wound the whole bandage round the patient's unpadded leg. 10 is malignancy distally with an Esmarch bandage;
days later at the follow up clinic the patient had a numb foot. you can use a simple tourniquet, though.
LESSON Learn how to apply a tourniquet, before you apply one.

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CAUTION! When you do apply it, apply 2 more winds than are
(1);A tourniquet on the forearm or on the lower leg is necessary to obliterate the pulse. When you have finished,
dangerous, because you may damage the radial nerve at it should feel moderately firm, but not rock hard.
the ulna, or the common peroneal nerve at the neck of the CAUTION!
fibula. (1);Do not apply a tourniquet over too narrow a band of
(2);Tie a tourniquet to the operating table, to prevent muscles.
anyone forgetting it, because the patient cannot later be (2);Do not ever wind on more than five turns after you
lifted off the table without removing it. have obliterated the pulse.
A tourniquet hidden under drapes can easily be forgotten. N.B. Every turn may add 100mm Hg more pressure.

THE SAFE TIMES for an adult of average build are: the TOURNIQUET TIME:
arm 1½hrs, the leg 2hrs. Shorten these times by 60% in a 1½HRS IN THE ARM and 2HRS IN THE LEG;
thin adult or in a child <8yrs. Apply a tourniquet to a 60% LESS FOR THIN ADULTS AND CHILDREN
finger for a few minutes only. The responsibility for
keeping within these times lies with the anaesthetist, EXSANGUINATING A LIMB
who should remind the surgeon every 15mins how long a INDICATIONS.
tourniquet has been applied, and write on a board in the Any operation in which you want a completely bloodless
theatre when it was applied. field, particularly orthopaedic.

ELEVATE THE LIMB for a few minutes before you CONTRAINDICATIONS.

apply any kind of tourniquet. If you are going to apply an (1) Sepsis.
Esmarch bandage, now is the time to apply it. (2);Amputations for malignancy. It may spread both of
these.
REMEMBER TO USE ANALGESICS if you keep a
tourniquet on for more than 30minutes: they are painful! AT THE END OF THE OPERATION
There are 2 ways of controlling bleeding after you have
PNEUMATIC TOURNIQUET. Place a folded towel, or a applied a tourniquet:
thin layer of cotton wool, around the limb at the site where (1);Release it just before you close the wound.
the tourniquet is to be applied. Wrap this snugly round the Use this method when you do a fine operation on the hand,
limb: it must not be loose. Pump it up to the appropriate for example. It will reduce the blood clot in the tissues,
reading for 'arm', or 'leg', on the scale. For a child use a and the stiffness and fibrosis that this might cause.
lower pressure as indicated on the scale. Drape it out of the Release the tourniquet, raise the limb, apply large swabs
way of the operation, but keep the dial where you can read to the wound, and press on them firmly for 5 minutes.
it. If the bag becomes contaminated, autoclave it (2.4). Normally, bleeding will stop, though, you should expect a
measure of post-operative bleeding.
USING A SPHYGMOMANOMETER AS A (2);Release it at the end of the operation after you have
TOURNIQUET. closed the wound. Use this method after operations in
On the leg apply the cuff over the femoral artery. On the which clot in the tissues will be less important, as when
arm apply it as if you were taking the blood pressure (BP), you do a sequestrectomy (7.5). Tie any major vessels when
or if necessary higher up the arm. Bandage it in place with you meet them during an operation. When the operation is
a firm unyielding bandage, and fix this with adhesive complete, suture the wound, apply a dressing, and let
strapping. Inflate the cuff until the distal pulses just down the tourniquet. Remove the pressure dressing 48hrs
disappear. Remember the pressure, and let the cuff down later. Usually, this is all that is necessary.
again. When you want to use the cuff, blow it up to Observe the circulation in the limb at least hourly;
80-100mmHg above the pressure which just stops the the capillary reflex is important, so pinch the nail beds.
pulses. This is about 200mm for the arm in an adult and Always check that a tourniquet is removed post-
180mm in a child. For an adult leg blow it up to 250mm. operatively: this must be part of the time out procedure
Ask an assistant to keep the cuff at this pressure, and to (1.8).
inflate it as necessary if the pressure drops.
CAUTION! Do not inflate any cuff to >80-100mm
above the pressure that will just obliterate the pulse.
3.5 Postoperative bleeding
USING AN ESMARCH BANDAGE
Raise the limb and squeeze blood out of it. Tape a folded After you have closed an operative wound it may start
towel or a thin layer of cotton wool in position over the bleeding:
limb. Apply the Esmarch bandage over c.12cm. Put on the (1);During the first 48hrs (reactionary haemorrhage)
first 2 layers of the bandage without pulling. because a clot in a vessel has been displaced, or a ligature
Next, do a trial run to find how many turns are necessary has slipped.
to obliterate the pulse. Pull out the bandage to about ¾ of (2):8-14days later (secondary haemorrhage) when the
its potential expansion length with each wind. Count how wound has become infected and eroded a vessel, usually
many winds you need to obliterate the pulse. quite a small one, sometimes a larger one.

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One of the purposes of monitoring a patient immediately If you aspirate large quantities of fresh blood
after an operation is to watch for reactionary haemorrhage, from a nasogastric tube after upper gastro-intestinal
so make sure your staff observe carefully for early signs of surgery, there is probably bleeding from a suture line. This
blood loss, and understand what to do. is unlikely to stop spontaneously. You will probably need
to re-open the abdomen to deal with the problem.
If a wound bleeds, try firm local pressure and packing.
If it bleeds briskly, you may have injured an artery, such as If there is bleeding some days after a laparotomy,
the inferior epigastric. Minor bleeding is probably coming the blood may be coming from a stress ulcer, or from a
from the subcutaneous tissues, and is unlikely to be pre-existing duodenal ulcer unrelated to the previous
serious. pathology. This may threaten life. Treat this as described
(13.4).
If local pressure fails to control bleeding, do not apply
more and more dressings; take the patient back to theatre, If blood is not clotting properly, check the clotting time.
open and, if necessary, enlarge the wound. Take 5ml into a dry glass tube; invert it every 30 seconds,
Irrigate it thoroughly with warm water. You can usually do keeping it at body temperature, and time when it clots.
this under LA. Remove the sutures and tie (3.2) If this takes >8mins, there is a clotting defect.
or coagulate any bleeding vessels that you can see: you Administer 10mhg vitamin K IV. Use whole blood or
may need to put a running suture to control such bleeding. packed cells and FFP to replace the blood loss, to try to
Liga clips may be useful (4.10). replace the clotting factors.
If necessary, remove a pressure bandage or split a cast
lengthways and open it at least 2cm. If you need to Disseminated Intravascular Coagulation (DIC) may
immobilize an open fracture, loosely apply a well develop, especially with retained products of conception.
padded cast. You may need to re-apply the tourniquet, If blood clots in ≤2·5min, it is hypercoagulable: thereafter
but do not forget to remove it! if the clot lyses in 30mins, fibrin degradation has occured
If you have had to re-open a haematoma, add a single Use whole blood, FFP and fibrinogen 4 to 8gif available,
dose of prophylactic antibiotic (2.9) to correct the clotting disorder.

N.B. Particular operations, viz. draining a peritonsillar

abscess (6.12), removing a sequestrum (7.5), any
laparotomy (11.2,10), draining an empyema of the
gallbladder (15.4), cholecystectomy (15.8), liver biopsy 3.6 Complications of blood transfusion.
(15.11), laparotomy for pancreatic abscess (15.15),
splenectomy (15.17), block dissection of the groin (17.8), Blood is a dangerous substance and transfusion can cause
laparotomy for ectopic gestation (20.6), Caesarean Section severe, lasting problems, even death. Your laboratory
(21.10), D&C (23.4), myomectomy (23.7), hysterectomy ought to be able to cross-match any blood you transfuse;
(23.15), mastectomy (24.5), thyroidectomy (25.7), otherwise you have to use O-ve blood only, but even then
prostatectomy (27.20), eversion of hydrocele (27.24), there may be significant dangers with this.
tonsillectomy (29.12), dental extraction (31.3) or varicose
vein ablation (35.1) all have their own specific hazards. The most important of these complications are
transmission of Hepatitis and HIV disease, and therefore
If there are signs of circulatory failure postoperatively, your laboratory must be able to check for these also.
with a fast pulse, pallor, perhaps with abdominal There remains the danger of the ‘window’ period for HIV
distension, confusion or even coma, this may be the result and so you should always think about auto-transfusion,
of: even in the presence of mild sepsis (5.3).
(1);Blood lost at the operation not being replaced,
especially if there was hypovolaemia before bleeding These are the commoner infections that can be transmitted
began. by blood transfusion:
(2);Fluid lost into the sequestrated bowel not being 1. Hepatitis A, B, C, D.
replaced. 2.;HIV disease.
(3);Anaesthesia too deep and depressed respiration, 3.;Malaria.
leading to hypoxaemia and hypotension. 4.;Staphylococcal (or other bacterial skin) sepsis.
(4);Overdosage of opioids, such as morphine or pethidine. 5.;Atypical mononucleosis (Glandular Fever).
(5);Use of a high subarachnoid (spinal) anaesthetic. 6.;Brucellosis.
(6) Septicaemia. 7.;Cytomegalovirus.
8.;Syphilis.
If bright red blood comes from a drain or incision, 9.;Yersinia.
there is profuse arterial bleeding. Restore the circulating 10. Trypanosomiasis.
volume with 2l Ringer’s lactate fast. Transfuse blood if the
systolic blood pressure remains <90mm Hg.
Do not wait till the blood pressure is normal!
Stop the haemorrhage!

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Apart from these, there may be ABO or Rhesus (Rh) LIFE-THREATENING EMERGENCIES.
incompatibility as well as 26 other types of
cross-reactions, as well as plasma reactions and problems Severe haemorrhage often occurs in unforeseen
related to the blood being still frozen, or overheated. circumstances. It is best to be prepared rather than sorry
A graft-versus-host disease can rarely occur producing an after the event. Try to keep at least 2 units of O-ve blood
ARDS-type lung injury. continuously available in your hospital, because there will
be no problem transfusing this in 99% of your patients.
Stored blood may have K+ of 40-70mM, so multiple If you cannot get O-ve, O+ve will be satisfactory for
transfusion may produce a dangerous hyperkalaemia, 85-95% of cases, so if a patient is in extremis, do not fear
and the citrate used to preserve its liquidity may produce a the risk of 5-15%!
worsening acidosis. However, often more importantly,
as stored blood loses its clotting factors after 24hrs, Fresh blood is often better than stored blood; try to have
coagulation becomes disrupted. Further the citrate soaks reliable persons (tested regularly HIV-ve) in your
up calcium, and this further aggravates bleeding. community available to assist in an emergency with blood
Haemorrhage may even be exacerbated by a consumptive transfusion.
coagulopathy producing DIC. Remember to try to correct clotting disorders, if present.

If your laboratory produces packed red cells (because N.B. Fresh Frozen Plasma can be stored for a long time
other blood products are filtered off), there are no platelets as opposed to blood and should therefore be available via
in the blood. the national/regional blood bank. However, as one unit is
Using whole blood avoids this problem and hold the collected from more than one donor, the risk of HIV,
clotting factors necessary for haemostasis. Stored blood is Hepatitis transmission etc. is that much greater.
just not as good!

However, there may be a greater risk of multiple

pulmonary emboli (the acute respiratory distress
syndrome), and an antigenic response producing release
of vasoactive substances and complement as well
as depressing the reticulo-endothelial system. Blood
transfusion definitely decreases immunity, and the risks of
recurrence after cancer surgery may increase by c. 10%.

Finally, if you transfuse an anaemic patient, especially if

his anaemia is chronic and compensated, you can so
increase the blood volume that you tip him into acute heart
failure. This is particularly important in children.

PROTOCOL.
Check the blood units individually for compatibility
(name, hospital & batch numbers, group) and expiry date.
Make sure an IV line is patent and flushed with saline.
Warm the blood (do not heat it up!). Check the blood unit
to be used again, and make sure it is signed for. Attach the
blood unit to a blood-giving IV infusion set (with a filter).
Observe the patient ½hrly for pyrexial or other reactions,
and chart infusion volumes.
N.B. Do not stop a transfusion because of a minor
pyrexia especially if the patient is septic anyway.
Administer 10ml (2.2mmol) 10% calcium gluconate IV
with every 4th unit of blood transfused.
N.B. 10ml of 10% calcium chloride IV provides 6.8mmol

Administer 20mg furosemide IV with each unit of blood if

cardiac failure feared.
Stop the transfusion if there is a serious reaction;
administer 100mg hydrocortisone IV, and preserve the
blood unit for laboratory analysis later.

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4 Basic methods and

You can save much on IV fluids by infusing water
instruments rectally: a patient will readily tolerate and absorb 500ml
over 6hrs.

If you have no Kirschner wires you may be able to use

4.1 Appropriate surgical technology: the the sharpened bicycle spokes. Do not store instruments of
the equipment you need ordinary steel sterilized in packs or drums: the interior of
these is damp and they will rust rapidly.
You may step into a beautifully organized theatre, or you STORES AND EQUIPMENT
may have to create it from scratch. To help you in this task
we have listed everything you might need to do the SUPPLY CYCLES. If your supply period for a consumable item
procedures we describe, down to the last needle and cake is 'x' months, try to keep 3 times the quantity of it you consume
of soap. To minimize the tediousness of long lists we have during this period in stock, so that one indent can go astray
described the equipment in the text. We have included without causing disaster.
everything which you could reasonably have, but may not When you order equipment, try to include the catalogue number.
have at the moment. For example, many district hospitals Where possible write to the supplier and ask for a 'proforma
do not have skin-grafting knives, pneumatic tourniquets, invoice' giving the exact details and costs, etc. This will make
ordering much easier. Obstetric equipment is discussed in 19.2.
simple bone drills, Kirschner wire, or manometers for
measuring the central venous pressure; but you could The theatre. Theatre furniture and lighting, gowns, gloves and
reasonably try to get them, so we have included them. drapes (2.1, 2.3), drains and tubing (4.9). Miscellaneous smaller
Some of the special methods we describe do not need any items of theatre equipment (4.11).
extra equipment: e.g. the plastic bag method for
laparostomy (11.10). Learn to recognize the instruments Preventing sepsis. Sterilizing equipment (2.4), antiseptics and
you use and to know them by their names. Remember the disinfectants (2.5).
instruments may have different names in different
countries! When you first arrive at a hospital check the Preventing bleeding. Haemostats and arterial clamps (3.1),
tourniquets (3.4).
theatre equipment and find out what is missing!
Cutting and holding tissues. Scalpels and dissectors (4.2),
When you order equipment that is not listed here try to scissors (4.3), forceps (4.4), retractors (4.5), suture materials
make sure that: (4.6), needles and their holders (4.7).
(1) It will work reliably (good quality) without needing to
be returned to the makers to be mended. Instruments for bones (7.5), bowel (11.3), obstetrics (19.2),
(2);It will work well in your hands and is electrically proctology (26.1), urology (27.1), eyes (28.1), ENT (29.1),
compatible. tracheostomy (29.15), dentistry (31.1, 31.3), chest aspiration
(3),You can afford both its initial and its running costs. (36.1).
(4) Spares are available.
(5);You can easily learn how to use it and teach other 4.2 Scalpels and dissectors
people to do the same.
(6);It can be repaired locally if need be. A sharp scalpel cuts tissue with less trauma than any other
Think about whether it needs to be portable, and so how instrument. There are 2 ways of holding one:
robust it needs to be. Don’t get persuaded by wily (1) If you need force to make a big bold cut, grasp it with
salesmen into buying things you don’t really need! your index finger along the back (4-1).
(2) If you want to cut more gently, hold it like a pen.
If you want to be well supplied, encourage and motivate
your storeman. Look at what there is and how he has The size of a blade does not change the way you use it,
organized things. Do not forget to visit your central but its shape does. A small blade allows you to make
medical stores; you may find things you need, which the precise turns. Some blades have very specialized uses.
storeman there cannot identify, and you can make good Use the stab point of a #11 blade to open an abscess.
use of. The equipment we list is the equipment he should Use #12 blades for removing sutures. Use a #15 blade for
stock. small incisions, and a #10 for larger ones; a #20-24 is best
for a laparotomy incision. The smaller blades (sizes 10-19)
You will certainly have to improvise. If you do not have fit onto the #5 Bard Parker handle, and the larger ones
the standard stainless steel instruments, do not hesitate to (sizes 20-36) onto the #4 handle. A guarded scalpel is
use ordinary steel ones, if you can buy, adapt, or make useful for special situations, like tonsillar (6.7) and
them. You will need to wipe these carefully with an oily retropharyngeal abscesses (6.8). A fixed scalpel is
rag after each operation. For example, you can use an especially useful for symphysiotomy (21.7). If you find the
ordinary steel carpenter's drill instead of a bone drill, and a scalpel difficult to use at first, use sharp scissors, but as
sterile pair of ordinary pliers may be the best way to your experience grows you will find the scalpel easier and
remove a plate. safer.

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Beware cutting yourself or an assistant when using sharp SCALPEL, solid forged, size #1, 30mm, and size #5, 40mm.
If your disposable blades are exhausted, you can use a solid scalpel and
instruments!
re-sharpen it (4-3), whereas you cannot re-sharpen a disposable blade.
Make sure you have secured the blade tightly on the HANDLE, scalpel, Bard Parker, #4. Get good quality handles, because
handle, because if you lose it in a body cavity it is poor ones may not fit the blades.
difficult, and hazardous to find it again! HANDLE, scalpel, Swann Morton, #5.
BLADES, scalpel, disposable, Bard Parker or Swann
Morton type, stainless steel.
OILSTONE, hard Arkansas pattern, 150x70x30mm.
Use this to sharpen scalpels and scissors. A very blunt
instrument needs a carborundum stone first.
DISSECTOR, MacDonald. A blunt dissector is often
safer than a scalpel. This is a blunt general purpose
dissector, with 1 straight flat end and 1 round curved
end, neither of which are likely to injure anything.

4.3 Scissors

The tips of a pair of surgical dissecting

scissors are usually rounded; scissors in
which both tips are pointed are only used for
very fine dissection. Look after your scissors
carefully. Use straight scissors near the
surface and curved ones deeper inside.
Hold them with your index finger resting on
the joint. Use only the extreme tips for
cutting.

You can also use scissors for blunt dissection

by pushing their blades into tissues and then
opening them. This will open the tissues
along their natural planes, and push
important structures, such as nerves and
blood vessels, out of the way. This is the
'push and spread' technique (4-9B). If there
is something nearby which it would be
dangerous to cut, blunt dissection is always
safer. But remember that even blunt
dissection can injure veins, and that venous
bleeding can be very difficult to control.

Remember:
(1);Do not use sharp-tipped scissors in
dangerous places, or cut what you cannot
see.
(2);Do not use scissors which are longer than
the haemostats you have, or you may find
yourself cutting a vessel which you cannot
reach to clamp.
(3);Mayo's, McIndoe's, and Metzenbaum's
scissors are intended for cutting tissues,
so do not use them for anything else.
Use other scissors for cutting sutures and
Fig. 4-1 SCALPELS AND HOW TO USE THEM. dressings.
The advantage of a solid forged scalpel is that you can resharpen it. (4);Carefully keep and pack very fine scissors,
It is useful for symphysiotomy (21.7). Take care when you remove a e.g. ophthalmic instruments, separately.
blade: always use an instrument, hold the blade with the sharp side
away from you and never your fingers or plastic forceps!
(5);Beware, when passing scissors to do so holding the
Dispose of sharps in special containers (5.3). closed tips, so that your assistant or scrub nurse can take
them by the handle. Alternatively, place them on a special
tray.

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Note that it is not necessary or even desirable to have all SCISSORS, bandage, angular, Lister, 180mm. These have a blunt knob at
the end of one blade which goes under the bandage to protect the patient.
these sorts of different scissors.
Insert them away from the wound; if they become soiled or wet, clean
Make sure you look after your sharp instruments carefully. and sterilize them before you use them on someone else.
Buy good quality scissors, and do not autoclave them
mixed together with the other instruments. The very best
ones have tungsten carbide inserts, which make their
cutting edges last much longer. These are 4 times more
expensive, but justify their extra cost.

IN DANGEROUS PLACES BLUNT DISSECTION IS

SAFER THAN SHARP DISSECTION WITH
SCISSORS

Fig. 4-2 SCISSORS.

Mayo's, McIndoe's, and Metzenbaum's scissors are intended for
cutting tissues, so do not use them for anything else. Use other scissors
for cutting sutures and dressings.

SCISSORS, operating, Mayo, straight, bevelled, 200mm. Use these for

cutting sutures.
SCISSORS, operating, Mayo, curved, bevelled blades, 170mm.
These tissue scissors are curved in the plane of the blades.
SCISSORS, operating, McIndoe's, curved, with rounded tapering blades,
180mm. These elegant tapering tissue scissors are curved perpendicular to
the plane of the blades. Fig 4-3 CARING FOR YOUR EQUIPMENT.
SCISSORS, operating, Metzenbaum, curved 275mm.These have long A,C, grindstones. B, strop. D, if your razor is hollow-ground, lay it
handles and quite narrow blades. Use them for dissecting at the bottom of flat, so that both edges rest on the stone and push it forwards.
a deep wound. E, if it is ground on the flat, lift its heel slightly and push it forwards.
SCISSORS, Aufrecht's, light, curved, 140mm. This pair of scissors is for F, light reflecting from the blunt edge of a razor. G, no reflecting
the set of instruments for hand surgery. light from a sharp razor. H, removing a burr. I, stropping a knife by
SCISSORS, straight with fine sharp points, Glasgow pattern, 100mm, pulling it towards you. J, feeling if there is a burr on a blade by
stainless steel. Use these very fine scissors for cutting down on veins. drawing it backwards across your finger (make sure you do this when
SCISSORS, suture cutting, 'assistant's scissors', rounded ends. Keep these the blade is sterilized). K, sharpen a cutting needle by rotating it in
in spirit with the other scissors. Your assistant needs a pair; so does the 2 planes on a stone. L, sharpen a pair of scissors against a grindstone.
scrub nurse. M, tighten the rivet of a pair of scissors with a light hammer.
SCISSORS, suture wire cutting, 130mm. If you cut suture wire with N, the cutting edges of scissors should look like this.
ordinary scissors, it will ruin them.

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4.4 Forceps FORCEPS, dissecting, thumb, blunt, non-toothed, Bonney's, 180mm.

Dissecting (thumb) forceps can be short for working These are strong dissecting forceps without teeth.
FORCEPS, dissecting, thumb, toothed, Treves', 1x2 teeth, 130mm.
close to the surface, or longer for working more deeply. These are the standard toothed dissecting forceps.
They can be plain, or toothed with an odd number of teeth FORCEPS, dissecting, thumb, fine, Adson's, (a) plain, (b) 1x2 teeth,
on one jaw, and an even number on the other, either 1 into 120mm. These have broad handles and fine points and are particularly
2 teeth, or 3 teeth into 4, etc. Toothed forceps hold tissue useful for the eye.
FORCEPS, dissecting, thumb, Duval's, 150mm, with non-traumatic teeth
so firmly that only a little pressure is necessary; but they on triangular jaws. These are thumb forceps for general use.
can easily puncture a hollow viscus or a blood vessel. FORCEPS, dissecting, thumb, toothed, 180mm. These are long fine
Strong, plain, straight forceps without teeth are even more dissecting forceps.
useful for blunt dissection than they are for holding FORCEPS, dissecting, thumb, Maingot's, 280mm. These are large toothed
forceps with fenestrated sides that are easy to hold.
tissues. FORCEPS, dissecting, McIndoe's, plain, 150mm. These are for the hand
set.
FORCEPS, dissecting, ophthalmic, Silcock's, 100mm. This is a fine pair
of forceps for operating on the eye or the hand.
FORCEPS, tissue, locking, Allis, box joint, 150mm, 5x6 teeth.
FORCEPS, tissue, locking, Babcock's, box joint, 160mm. These have a
bar on each blade that comes together gently without damaging the
tissues. Use them to hold bowel.
FORCEPS, tissue, Lane's, 15cm. These have curved jaws, teeth and a
ratchet.
FORCEPS, sinus, Lister, box joint 150mm. You can use these for many
other purposes besides exploring sinuses. Use them for packing the nose,
or putting a drain into an abscess cavity.
FORCEPS, cholecystectomy, curved jaws with longitudinal serrations,
Lahey's, box joint, 200mm. These forceps are useful for other purposes
besides dissecting out the cystic duct. If you put them into the tissues and
separate them, you can use their rounded ends to define arteries, veins
and ducts.
FORCEPS, intestinal, Dennis Browne, 180mm. Use these to pick up the
bowel during an abdominal operation, or a hernia repair.
FORCEPS, Moynihan, box joint, 220mm. Use this massive pair of
crushing forceps for wide vascular pedicles, such as those which contain
the uterine vessels at hysterectomy.
FORCEPS, Desjardin's, screw joint. Use these for removing stones from
the bile duct.
FORCEPS (clamps), hysterectomy, curved, box joint, 1 into 2 teeth,
23cm, Hunter or Maingot. Hysterectomy is difficult without several long
curved clamps for big vessels, preferably with longitudinal serrations and
teeth at their tips.
FORCEPS Magill’s. Use these in endotracheal intubation and for
removing foreign bodies in the throat (30.1).

N.B. It not necessary nor even desirable to have all these

sorts of different forceps.
Fig. 4-4 FORCEPS.
Dissecting forceps are also called thumb forceps, and can be plain or
toothed. Use forceps according to the size of tissue you are handling:
Lane's tissue forceps have teeth and are useful for holding a large 4.5 Retractors & hooks
piece of tissue you are going to excise; Bonney’s for the abdominal
wall; Treves or Adson’s for skin; Duval’s have a groove to hold tissue
with minimal trauma to it; Babcock's have bars on each blade that You will need a retractor to hold tissues out of the way of
come together gently without damaging the tissues, and so are useful where you want to operate. There are 2 kinds. One has to
for holding bowel or ureter which you don’t want to damage;
Sponge-holding forceps for gauze swabs, or to retract the gallbladder be held by an assistant, the other holds itself.
(15.8). Magill’s are specifically for guiding an endotracheal tube,
but also for extracting foreign bodies from the throat (30.1). Self-retaining retractors should never stretch a wound and
cause ischaemia: make a bigger incision if the field is
Tissue (locking) forceps have a ratchet which keeps them inadequate! Strong retraction causes trauma, especially to
closed. Some have teeth (Allis) and some have none the edges of the wound. So avoid it by approaching deep
(Babcock's). The blades of Allis forceps meet together, areas through larger incisions. Avoid sharp, pointed
and inevitably injure the tissues a little, whereas Babcock's retractors.
have bowed jaws with a gap between them. This makes
them gentler but less secure. When you use Allis forceps Any blacksmith should be able to make you the simpler
for retracting a skin flap, apply them to the subcutaneous retractors from ordinary steel.
tissue or fascia, and not to the skin itself, which may be
injured. Kocher's forceps are stronger, have a toothed end, If you need an assistant to hold a retractor for a
and are even more traumatic; they are for clamping fascia considerable length of time, engage him in the operation
or wide vascular pedicles, so that the vessels do not slip lest his concentration wanders at a critical moment!
out (3.1).

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4.6 Suture materials

If you bring soft tissues together and hold them there for
5-10days (depending on their blood supply) they will join.
Most surgery depends on this. The easiest way to hold
tissue is to suture it. You can use:
(1) Absorbable sutures which are absorbed by the tissues
so that you need not remove them.
(2) Non-absorbable ones which you leave indefinitely if
they are deep, or remove if they are on the skin.

Absorbable sutures used to be solely plain catgut (from

the submucosa of the bowel of sheep, not cats!) which
usually holds its strength for about 10days. Catgut can be
treated with chromic acid which slows its absorption by
phagocytosis and makes it keep its strength for 20days,
but this remains unpredictable. Sepsis speeds the
dissolution of catgut, especially plain catgut, so that it may
dissolve in 2-3days. Catgut is soft and holds knots well,
but not so well as a non-absorbable multifilament, such as
linen or cotton. If a suture material does not hold knots
too well, its knots need longer ends (>5mm). While catgut
is being absorbed it makes a good culture medium and
may promote sepsis. So do not use more than is necessary,
do not leave the ends of ligatures unnecessarily long and
avoid thick #2 or #3 catgut. Plain catgut does not hold its
strength for very long, so never use it for tying larger
vessels or suturing the bowel. One problem with catgut is
that it may be of poor quality, and does not preserve for
long, and so give way early and perhaps disastrously.
Fig. 4-5 RETRACTORS.
You cannot operate on a patient if the surrounding tissues get in your
This is another reason for using monofilament where you
way. These retractors will help to give you a clear field. Some have to can.
be held, others hold themselves.
If necessary, you can use almost any suture material
RETRACTOR, Volkmann's rake, sharp, 4 prong, 220mm. These have almost anywhere, especially on the skin. But, always use
sharp teeth like a cat's paw. Take care that they do not injure anything
important.
absorbable for:
RETRACTOR, Langenbeck, 13x44mm. These are fairly small narrow (1);The urinary and the biliary tracts because non-
deep retractors. absorbable sutures can act as the focus around which a
RETRACTOR, Czerny, double ended. These have a flat blade at one end stone can form.
and 2 deep prongs at the other. They are thus more versatile than
Langenbeck's retractors.
(2);The mucosa of the stomach, where a non-absorbable
RETRACTOR, Lane's modified by Kilner, double ended, 150mm. suture may be the site of an ulcer later.
This is a light general-purpose retractor with short shallow hooks at one (3) The mucosa of the uterus (less important).
end and a tongue at the other. (4);Sutures close under the skin, where non-absorbable
RETRACTOR, Gelpie, 170mm. A pair of these are very useful as general
purpose retractors.
sutures may work their way to the surface.
RETRACTOR, Morris, double ended. This is a double ended abdominal (5);The scrotal skin, where sutures easily “disappear” and
retractor. Some surgeons prefer single-ended ones which are easier to cause intense itching.
hold.
RETRACTOR, Deaver's, plain handles, set of five sizes.
These inexpensive general purpose abdominal retractors nest together,
There are long-lasting absorbable sutures which are more
and so are easy to store. reliable, but they are expensive. It might be useful to have
RETRACTOR, malleable copper, set of 4 sizes. These are strips of copper limited stocks for special purposes, e.g. bowel
that you can bend into any shape to suit your needs. anastomosis, where suture breakdown is a disaster, and the
RETRACTOR, Meydering, 178mm. These are for hand surgery and are
used as a pair.
extra cost readily justified. Various synthetic materials are
RETRACTOR, self-retaining, West's, straight, sharp-pronged. used, with different absorption times:
This is a small self retaining general-purpose retractor. Polyglycolic Acid (‘Dexon’, ‘Polysorb’) 30-60 days
RETRACTOR, abdominal, self-retaining, 2-blade, adult, Gosset's. Polyglactin (‘Vicryl’,‘Visyn’) 60-90 days
The 3 blades of this large abdominal retractor can be arranged so that
they support one another, and do not have to be held. Lactomer 9-1 (‘Clinisorb’) 60-90 days
RETRACTOR, universal, Dennis-Browne, with (a) 1 frame 300x240mm, Poliglecaprone 25 (‘Monocryl’) 90-120 days
(b) 3 hook-on retractors 50x65mm, (c) ditto 80x90mm, (d) ditto Glycomer 631 (‘Biosyn’) 90-120 days
98x50xmm, (e) ditto 105x35mm. This is a useful but expensive retractor.
It has a notched ring and hooked prongs (4-5). Polydioxanone (‘PDS’) 120-180 days
HOOKS, tendon, Harlow-Wood, 114mm. These are for the hand set NB. Vicryl rapide has a much shorter absorption (10-15 days) and Vicryl
(4.12). plus (preserved in triclosan antiseptic) longer.

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Non-absorbable sutures can be polyamide ('Nylon'),

polypropylene ('Prolene', ‘Surgilene’, ‘Surgipro’),
polyethylene ('Courlene'), polyester (‘Dacron’,
‘Mersilene’, ‘Surgidac’), which may be coated with
polybutilate (‘Ethibond’) or silicone (‘Ticron’), linen,
cotton, silk, or stainless steel wire. The first three come as
a single (mono)filament, or as multiple filaments which
are braided or twisted together. Monofilament is the most
useful general purpose suture. Although non-absorbable
sutures remain as permanent foreign bodies, monofilament
nylon, polyethylene, and steel are less likely to promote
infection than catgut, or multifilament cotton, linen,
or silk.
Unfortunately, a single thicker filament makes less reliable
knots than a many finer ones braided or twisted together,
except for steel wire, which is always used as a single
filament, and which knots superbly but is difficult to work
with. So, always tie monofilament with a surgeon's knot
(4.8). Silk, linen or cotton knot well, and you can cut these
sutures 2mm from the knot.
Apart from the indications for absorbable sutures given
above, you can use monofilament for almost anything,
but silk, cotton, or linen threads, are better than
monofilament for tying larger vessels. However, never
hold monofilament with artery forceps or a needle holder
because you will seriously weaken it at that point. Braided
silk may cause troublesome stitch abscesses. Do not use it
immediately under the skin, because it may work its way
through to the surface, long after healing is complete.
If it does become infected, you may have to remove it
piece by piece. Even monofilament can come to the
surface, so keep it well buried, and use absorbable close
under the skin. Fig. 4-6 BUY MONOFILAMENT IN REELS.
The strength of sutures is measured in 2 systems. Hang them from a wall bracket (A), cut lengths of suture material
In the old system the finest ones are measured in 'zeros' about a metre long and twist them into loose coils (B,C), or wind
them round the empty spools used for disposable sutures.
and the thicker ones are numbered. From finest to thickest If funds are scarce, avoid the expensive proprietary sutures F,G;
the sequence is, with doubling of diameters each time, you can also use cotton or linen thread, or colourless fishing line.
6/0, 5/0, 4/0, 3/0, 2/0, 0, 1, 2, 3, 4. Although attempts are Match this against surgical monofilament nylon strength for
being made to replace the old system by a metric one from strength. A good strength for abdominal sutures is 12-20lb breaking
strength.
0-8, most surgeons still use the old one.
Use the thinnest sutures you can: they need only be as Dr JAMES MUKOLAGE was horrified to find in the village a woman
strong as the tissues they are holding together. You can do with an abdominal wound from which bowel was protruding. He was
most operations with sutures between 3/0 and 1. Only very only recently qualified and had not operated on one of these cases before.
He had few facilities, but he managed to find some local anaesthetic
occasionally will you need sutures which are thicker or solution and some linen thread in the shops. A few instruments from the
thinner than this, except for fine work such as nerve or local health centre were boiled up; he washed the wound thoroughly, and
tendon repairs, and for eye and plastic surgery. If you do anaesthetized the tissues round it with lidocaine. Fortunately, her bowel
need a thicker suture, you can double up a thinner one. had only a minor cut in it which was easily repaired. When he had
returned her bowel to her abdomen he was able to close it with linen
The cost of sutures can significantly increase the cost of thread. She survived. LESSON: Improvisation can save lives.
an operation. In the industrial world they are now sold in
individual disposable packs, which are expensive to make MONOFILAMENT IS THE MOST USEFUL
and waste much suture material each time a pack is GENERAL PURPOSE SUTURE MATERIAL
opened. (If the outer wrapping is opened in error, the
suture is still sterile and should not be discarded!) Never let the lack of suture materials be the reason for not
The suture is combined with an atraumatic needle and this doing an urgent operation. Either use ordinary nylon
means that sutures for one operation may cost US$20. fishing line, which is exactly the same material as that
But if you buy monofilament in rolls, and use ordinary used for surgical sutures. Thread this through a hollow
needles, the suture materials for a single operation cost sterile needle of correct size, snap off the plastic Luer lock,
almost nothing. Monofilament suture material in packets is and crimp the metal of the needle tight onto the thread to
20,000% more expensive than in reels, and with needles secure it. Bend the needle to whatever shape you want and
swaged on is 30,000% more! use it with a needle holder.
Here are comparative suture sizes related to fishing wire
breaking strengths:

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Non-absorbable Diameter limits Fishing line size by breaking Improvised syringe needle gauge
suture size, (mm) strength (in pounds) and Uses and inner diameter (mm)
U.S.P. (and approximate diameter
metric)
6-0 (0.7) 0.070 - 0.099 N/A Face, blood vessels 30g (0.140) or 31g (0.114)
5-0 (1) 0.100 - 0.149 1 lb (0.12-0.14 mm) Face, neck, blood vessels 28g (0.191) or 29g (0.165)
4-0 (1.5) 0.150 - 0.199 2-4 lb (0.15-0.20 mm) Neck, hands, limbs, 26g (0.241) or 27g (0.216)
tendons, blood vessels
3-0 (2) 0.200 - 0.249 6 lb (0.22-0.26 mm) Limbs, trunk, bowel, blood 23g (0.318); 24g (0.292) or 25g (0.267)
vessels
2-0 (3) 0.300 - 0.339 8-10 lb (0.30-0.33 mm) Trunk, fascia, viscera, 22g (0.394)
blood vessels
0 (3.5) 0.350 - 0.399 12-14 lb (0.32-0.39 mm) 20g (0.584) or 22g (0.394)
1 (4) 0.400 - 0.499 15-20 lb (0.40-0.48 mm) Abdominal wall closure, 20g (0.584)
2 (5) 0.500 - 0.599 25-30 lb (0.50-0.58 mm) fascia, muscle, drain and 18g (0.838)
3, 4 (6) 0.600 - 0.699 N/A line sites, bone 18g (0.838)
5 (7) 0.700 - 0.799 50 lb (0.70-0.77 mm) 18g (0.838)
N.B. The thickness of fishing line is not necessarily
proportional to its breaking strength!
Or, if necessary, you can use ordinary linen or cotton
thread almost anywhere, especially as ties. You can The narrower and deeper the space the smaller and more
likewise buy this cheaply on a reel, and re-sterilize it. curved the needle has to be. If necessary, you can try to
Use 4/0 monofilament as your basic suture material for fine skin bend a half-curved needle into a ⅝ circle. To economize
sutures. on commercially-produced sutures, you can use fishing
SUTURES, catgut, plain, 3/0, in boxes of 12. Plain catgut is soft. wire (4.6).
Use it for suturing the mouth, tongue, and lip.
SUTURES, absorbable, strengths 3/0, 2/0, 0, 1 and 2. A needle can have an eye, or the suture material can be
SUTURES, absorbable long-lasting, atraumatic, (a) 2/0 on half circle
fixed to it to form an atraumatic needle. These are
30mm needles. (b) 2/0 on 5/8 circle 30mm needles. (c) 4/0 on 16mm
curved needle. These sutures have needles swaged on to them. expensive, but they make smaller, neater holes, because
Use them for the bowel, the gall-bladder, and the stomach, held in a the suture material is not doubled through the extra
needle-holder. The smaller needles (c) are for children. thickness of the eye. Use atraumatic needles to suture
SUTURES, prolene, atraumatic, (a) 4/0 on 16mm half circle, round-
bowel, the urinary tract, blood vessels, nerves, the cornea
bodied needles, (b) 8/0 on 3mm 3/8 circle atraumatic needles.
SUTURES, linen, # 1. Use linen for tying vessels. It holds knots well and and the face, especially the eyelids. These commercially
is stronger than cotton. available sutures are much easier to use. It is worthwhile
SUTURES, nylon or virgin silk, 8/0. These are for suturing the cornea. trying to get them through donations. Though they have
WIRE, monofilament, soft stainless steel, (a) 5/0, (b) 0.35mm, (c) 1.0mm,.
commercial expiry dates, their reliability lasts at least
Surgical wire must be soft and malleable because springy wire is difficult
to work with. Autoclave the whole reel. 12-24 months past this date.
(a) Fine 5/0 wire is cheap, and is excellent for the skin, if you can use it
efficiently. Always use a cutting needle for the skin, either a straight,
(b) 0.35mm wire is for wiring the teeth and for hemicerclage.
half-curved or a large curved one held in your hand, or a
(c) Tension 1.0mm wire in a stirrup and use it for exerting traction.
These wires and the equipment to use them are essential. One of the smaller curved one held in a needle holder. Use a cutting
advantages of wire is that, unlike more massive pieces of metal, it does needle for tough fascia. Mayo's needle is a hybrid: it has a
not promote infection, so that you can if necessary put it though infected trocar point and a curved round shank. Use it for big wide
tissues. You can wire tissues in the presence of sepsis; for example, when
vascular pedicles and tough tissues, such as ligaments.
you repair a burst abdomen (11.14).
Fasten wire by passing its ends through any convenient tube, such as that Use round-bodied or taperpoint needles for most other
from a ball pen, and then grasping the ends and twisting them. tissues, because of the danger of needle stick injuries.
Finally, cut the twisted ends of the wire short. This will prevent it from Re-sharpen cutting needles on a stone (4-3).
coiling up in an inconvenient way.
WALL BRACKET, stainless steel, to hold rolls of monofilament (4-6).
Fix this to the wall, and pull lengths of monofilament from it. If you You will want a needle-holder to hold small needles and
cannot get one of these brackets, make it. suture in a confined space. Use a holder with a short
REELS, stainless steel, egg shaped ('eggs'), for holding suture material. handle near the surface, and a long one deeper inside.
Wind monofilament into these, autoclave them and cut off the length of
Use big needles in big holders, and small needles in small
suture material you require.
CRIMPING PLIERS, for bending needles. holders. A large needle can break a fine needle-holder
such as Derf's, so treat it with care. Needle-holders can
have plain jaws, or tungsten carbide inserts which prevent
4.7 Needles & their holders the hard steel of the needles wearing them away.
These cost twice as much, but last more than twice as long.
Needles can be round-bodied, taper-pointed, or they can Quality counts in needle-holders, so get good ones.
have cutting edges. They can be thin or thick, large or Hold the needle at the middle of its curvature at the very
small; straight, J-shaped, or curved into ¼, ⅜, ½, or ⅝ of a tip of the needle holder, and follow the curvature of the
circle. Curved needles are for working in confined spaces. needle when you draw the suture through the tissues.
Use a ⅜ circle needle in a shallow space, and a ⅝ needle in
a deep one.

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NEEDLES, suture, Keith, triangular straight 64mm. This is the standard

straight, hand held needle for stitching skin. It is easy to sharpen and
1 needle may last you a year.
NEEDLES, suture, 3/8 circle, curved, triangular point, size 4, 12, & 18.
These are the standard curved needles. Hold the largest ones in your hand
and the smaller ones in a holder.
NEEDLES, suture, 1/2 circle curved, triangular, size 2, 8, 14 & 20.
Use these strong, triangular cutting needles for the scalp.
NEEDLES, suture, round bodied, 3/8 circle curved, size 4, 10 & 18.
Use these for suturing soft tissue such as the peritoneum and broad
ligament.
NEEDLES, Moynihan, 5/8 circle curved, round bodied, fine, size 1, 4, & 6.
NEEDLES, Mayo, intestinal, round-bodied, half circle curved with sharp
perforating ends, 23mm, size 20. Use this small curved needle in a holder.
NEEDLES, suture, round bodied, ½ circle curved, size 1, 4, 10, 15, & 20.
Hold these in a holder and use them in the depths of a wound.
NEEDLES, suture, Moynihan, Lance point, 5/8 circle, 115mm.
Use these large curved needles for sewing up the abdomen (11.8).
NEEDLES, suture, curved, tension, Colt, 102mm. This is a very large
curved needle used for tension sutures into the abdomen (11.8).
NEEDLES, straight triangular, cutting, 35mm. Hold these in your hand
and use them for suturing tendons.
NEEDLES, suture, Jameson Evans, triangular, curved, 10mm.
These small curved needles have flattened shafts, triangular points and
lateral eyes. Use them for delicate sutures, such as repairing the eyelids.
NEEDLES, suture, Dennis Brown, round pointed, 5/8 circle, 16mm.
Hold these small curved needles in a needle holder, when you are
working at the bottom of a narrow deep hole, such as the bottom of a burr
hole.
NEEDLES, suture, 1/2 circle, catgut, Mayo, size 1 & 3. These are strong
needles for tough tissues. They have short cutting edges, so you can use
them to repair an artery.
NEEDLE, Deschamps, angled to the right. This is the only needle
(not illustrated) in this list which you can use to thread wire, to close the
abdomen (11.8), or to wire the patella.
NEEDLE HOLDER, Boseman, 210mm, ratchet and box joint, tungsten
carbide jaws. This is the standard needle holder for medium and large
needles.
NEEDLE HOLDER, Mayo's, with ratchet &box joint, tungsten carbide
jaws 185mm.
NEEDLE HOLDER, Mayo Dunhill, 160mm, ratchet & box joint, tungsten
carbide jaws.
NEEDLE HOLDER, Mayo's with narrow serrated jaws, box joint,
tungsten carbide jaws and ratchet, 185mm.
NEEDLE HOLDER, Derf, box joint and rachet, tungsten carbide jaws,
115mm. This is an expensive fine needle holder for tiny needles.

4.8 Suture methods

SUTURING WOUNDS (GRADE 1.1)

Fig. 4-7 NEEDLES. There are 2 kinds of wound to suture:

A, Atraumatic suture with a needle swaged on to it especially for (1) Those caused by trauma.
suturing bowel, vessels etc. B, ¼ circle, C, 3/8 circle needles.
D, ½ circle needle for suturing soft tissues such as the broad (2) Those which you make yourself when you operate.
ligament. E, 5/8 circle needle for suturing deep in a wound. You can suture both in much the same way. Here, we are
F, J-shaped needle for access into a small deep wound. G, compound mostly concerned with the skin; the special sutures for
curved needle. H, half-curved needle. I, straight needle, especially for other structures are described elsewhere: arteries (3.2),
subcuticular skin closure.
Needles can be round-bodied (J), taperpoint (K), cutting (L), and bowel (11.3).
or reverse cutting (M). Remember, when you suture wounds, you are simply
N, The best needle holders have tungsten carbide tips. Hold a needle approximating tissue and skin edges. It is not your sutures
where its cutting edge joins the shaft, with no part of the jaws which promote healing, but the body’s own repair
protruding. O, Colt's large hand-held curved needle. P, Economize
on sutures by using fishing line (4.6), thread this through an injection mechanisms. So, do not tie your sutures too tight;
needle, break off the plastic Luer lock, withdraw the thread into the this causes ischaemia and ultimately tissue death, not
needle, and crimp it tightly onto the thread. Bend the needle to the healing. Place your sutures accurately and neatly to
shape you want. produce a scar as near invisible as possible. Put the patient
Partly after Robert Remis.
in as comfortable a position as possible so he does not
fidget while you suture!

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'Over-and-over' sutures are the most commonly used,

and can be continuous (4-8A) or interrupted (4-8B).
Each interrupted suture needs its own knot; each knot can
act as a nidus for infection; and each takes time to tie.
So continuous sutures are quicker, but they are also less
reliable, because, if the knot on a continuous suture unties,
or the suture breaks, or it cuts out, the whole wound may
open up. The loss of a single interrupted suture, however,
usually matters little. A beginner usually finds interrupted
sutures easier. If you wish, you can lock a continuous skin
suture to make it more secure; you can lock every stitch
(4-8G), or every few stitches.
Vertical mattress sutures (4-8C) take a superficial bite to
bring the skin edges together, and a deeper one to close the
deeper tissues; so they are useful for deeper wounds,
but they leave scars: they are usually interrupted.
Horizontal mattress sutures may be interrupted (4-8D)
or continuous, superficial or buried (4-8E), and are merely
alternatives to 'over- and-over' sutures without any special
merit, except that they are better at everting the skin edges.
Do not bunch together the skin edges tightly:
gentle approximation is all you require.
A subcuticular (or intradermal) suture brings the skin
edges together accurately, and is particularly useful in
plastic surgery. By not puncturing the skin, it probably
leads to less wound infections. It can be interrupted (4-8F)
or continuous (4-8G). If it is continuous, anchor both
ends using a knot internally, or leave the end long.
(Abandon the use of threaded beads because of the danger
of needle-stick injury)
The simple mattress suture (4-9G) is different from the
figure of 8 suture (4-9H). Use this to stop bleeding from
soft bulky tissue when there is no obvious vessel to tie.
This can occur, for example, when you have closed the
uterus after Caesarean section with the usual 2 layers of
sutures and the wound is still bleeding at one end.
You may have donations of skin staples (4.10): they are
quick and easy to insert to approximate skin edges,
and leave little scarring, but need a special clip-remover to
get them out easily.

KNOTS AND SUTURES

SUTURING. Hold a straight needle in your hand.

Hold a curved one in a holder about half of its length from
its end, with no part of the needle-holder protruding
beyond the needle.
You will also have to hold the tissue you are sewing.
Hold a hollow viscus, such as stomach or bowel,
with plain forceps; hold skin or fascia with toothed ones.
If the needle is curved, move the holder through an arc, so
as to follow its curve.
In the skin, insert the needle a regular distance from the
Fig. 4-8 SUTURE METHODS FOR THE SKIN.
A, continuous over-and-over suture. B, simple interrupted sutures. edge of the wound, and place sutures regularly. Include an
C, vertical mattress suture. D, horizontal mattress suture. E, buried equal amount of skin on each side of the wound.
horizontal mattress suture. F, interrupted subcuticular suture. Set knots down so that they lie square, and do not tie them
G, continuous over-and-over suture which is being locked. too tight: just tight enough to bring the skin edges together.
After Grabb MD, Smith JW, Plastic Surgery, Little Brown 3rd ed 1979
Figs 1-8, 1-9, with kind permission. The skin will swell during the following day, and if the
knots are already tight, they will become even tighter and
impair the circulation, leading to necrosis.

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CAUTION! KNOTS. Tie reef (square) knots, not 'granny knots'.

(1) Do not insert the needle at different depths, because the These are both made from 2 half hitches; in a reef knot
edges of the wound will overlap. they go in opposite directions, in a granny knot they go in
(2) Do not leave dead spaces, or they will fill with fluid the same direction. Pull equally on both ends,
which may become infected. pull horizontally, and watch the knot go down. If one end
(3) Suture towards you. is tense and the other loose, you will get a slip or sliding
(4) When you suture 2 tissues together, one of them may knot.
be mobile and the other fixed (because you are holding it).
Suture from the mobile tissue towards the fixed.
(5) Continue in the curve of the needle.

Fig. 4-9 SOME OF THE BASICS.

A, Sponge holder grasping a swab ('a swab on a stick') can be a
useful instrument for dissecting delicate structures, as when
separating the peritoneum from the vagus nerves (13-13).
B, as well as cutting with scissors you can push them into the tissues
and then gently open them to spread structures apart. This is the
'push and spread technique'. Be gentle! It is useful for tissue planes, Fig. 4-10 TYING A REEF KNOT: 1st METHOD.
but forceful spreading can injure thin walled structures, such as The standard method without using instruments. Difficult steps are
veins. C, A 'reef' or 'square' knot. D, A 'granny knot' which does not C, and D, in which you grasp one of the ends between your middle
hold so well. E, a surgeon's knot for monofilament has three hitches and ring fingers, and I, and J, where you do the same again.
(or 'throws') with 2 turns (or more) on the first 2 hitches and 1 turn
on the 3rd. F, A surgeon's knot with multifilament is less likely to slip A surgeon's knot is merely a reef knot with a 3 rd half hitch
and need only have a single turn on each of the three hitches.
Note that each hitch should ideally make a reef knot with the in the same direction as the 1st one. This 3rd half hitch
previous one. G, A mattress suture. H, A 'figure of 8' suture, which makes the knot less likely to undo. Some surgeons tie
is like a mattress suture, except that the needle is inserted in the same 3 hitches in all suture materials.
direction both times. Do not use this on the finger.

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Some suture materials undo more easily than others. REEF KNOTS can be tied in several ways.
Non-absorbable multifilament makes the safest knots. The 1st method (4-10) is the surest way of tying a knot and
Knots of braided suture seldom undo, but knots of is the one to use if you want to exert continuous pressure
monofilament undo much more easily. So either use a while you tie. In the 2nd method (4-11) use forceps in your
surgeon's knot or at least 4 hitches when you tie right hand. The 3rd (4-12) is an 'instrument tie' and is
monofilament. For important knots put ≥2 turns on the useful if one end of a suture is short, or if the knot is in a
1st and 2nd hitches. With multifilament a single turn is deep cavity. The short end can be quite short. First, make a
enough on each hitch. loop with the instrument in front of the long end. Grasp the
short end and pull it through this loop. Then pull the first
Practise these knots with string or your shoelaces, until half hitch tight in the plane of the knot. To make the
you can do them quickly, and do them blind. Learn the second half hitch, start with the instrument behind the long
various ways of doing them in the following order. end.

Fig. 4-12 TYING A REEF KNOT; 3rd METHOD.

If there is not enough room for your fingers, use forceps in each
hand. This is an 'instrument tie'. Notice that for the 1st half hitch the
instrument is in front of the long end (A), and for the 2nd one it is
behind (D). In this way you will tie a reef knot, not a ‘granny’ knot.

TO CUT A SUTURE almost close the scissors, slip their

open ends over the suture material, and move them gently
down towards the knot. Twist the tip to give you the length
of tail you want, then cut. Cut the tails of interrupted skin
Fig. 4-11 TYING A REEF KNOT: 2nd METHOD. sutures short enough to prevent them tangling in the next
This method is similar to 4-10 except that you are using forceps in
your right hand. Use it if you are working in a hole.
suture. Leave buried catgut sutures with 5mm tails, others
with 2mm tails. Cut buried sutures close beside the
surgeon's knot.

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CAUTION! Keep the tips of the scissors in view, N.B. Add 50% to these values for patients taking
and do not cut unless you can see what you are cutting. corticosteroids or cytotoxic medication.
AN ABERDEEN KNOT (4-13) is a useful method to When you remove a suture, try not to pull any part of the
secure a mass closure of the abdomen (11.8); hold the suture material which has been on the surface through the
suture in a loop and pass successive loops of the suture tissues, or you may contaminate the wound. Clean the
through the 1st loop, c. 4-6 times, and then pass a single skin, cut the suture where it dips under the skin with sterile
strand finally through the loop. Pull this taut, thus taking scissors or a blade. Remember that after 3wks a wound has
the slack off the loop, and creating the knot. You can then only 15% of the strength of normal skin, at 4months 60%,
bury the suture end by taking a bite through adjacent and only full strength at 1yr.
tissue.

4.9 Drainage tubes

Inserting a drainage tube may be the principal aim of

surgery, as when you drain the pleural cavity (36.1), or it
may merely be part of an operation, as in decompressing
the stomach when the bowel is obstructed (12-4, 12-6)).
You can also use tubes to drain pus and exudate.
The insertion of a tube for gastrostomy (13.9),
jejunostomy (11.7), caecostomy (11.6), and
cholecystostomy (15.4) are described elsewhere: first we
describe the use of nasogastric tubes, which are of great
value, even though they are a burden to nurses and an
irritation to patients.

TUBE, nasogastric, plastic, Ryle's, with several side holes near the tip,
Ch14, Ch16, Ch18. Transparent plastic tubes are better than rubber ones,
because they are less irritant, they do not collapse, and you can see what
is inside them. Most tubes have markings, the first at 45cm showing that
the tip is about to enter the stomach, and the second that it is in the
antrum.
TUBE, stomach, plastic, adult and child, assorted sizes Ch8-22.
These are critically important for making sure that a patient's stomach is
empty before he is anaesthetized, and for washing it out if he has
swallowed a corrosive (30.3). Adults need tubes of Ch16-22, children
Ch10-14, and infants Ch8-10.

A. NASOGASTRIC (NG) TUBES

INDICATIONS.
(1);To remove fluid from the stomach before anaesthesia,
so as to reduce the risk of the inhalation.
N.B. The solid food from a recent meal will not come up
Fig. 4-13 AN ABERDEEN KNOT. a small nasogastric tube, so if you want to anaesthetize a
This is a very secure knot, especially useful for securing an patient safely who has recently eaten, or has intestinal
abdominal closure. obstruction, you will have to empty the stomach with a
large nasogastric tube.
REMOVING SUTURES. Leave them until the wound has (2);To decompress the stomach during upper abdominal
healed adequately. Some sutures can be removed on the surgery or in cases of high intestinal obstruction.
2nd day, others not until the 14th. Remember the function (3);To keep the stomach empty after a laparotomy for
of sutures is simply to approximate tissues, not to tie edges acute intestinal obstruction and in cases of pancreatitis.
together! Here is a guide: (4) To feed a patient.
(5) To monitor severe gastric bleeding.
Skin sutures on the face and eyelids 2-3 days
The tongue 4 days For all these reasons, it is good practice to pass a tube
The scrotum 5 days whenever you do an emergency laparotomy. It is, however,
The scalp 6-7 days not necessary with simple cases of appendicitis,
The arm, hand and fingers 7 days cholecystectomy, or elective bowel resection and most
The abdomen: transverse incision 7-9 days gynaecological procedures.
vertical incision 9-11 days
The skin of the back over the shoulders 11-12 days
The skin of the legs 14 days

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CONTRA-INDICATIONS. CAUTION! If you do not care for the mouth

(1) If you suspect oesophageal varices. adequately, the parotid may become infected. So arrange
(2);After corrosive injury of the oesophagus where the 4hrly mouth care as a routine after major surgery,
mucosa is friable and easily perforated. especially if there is a nasogastric tube in situ.
(3);Where there is severe respiratory embarrassment:
(a gastrostomy (13.9) is better). REMOVING A TUBE.
(4) A deformed or blocked nasal passage. As a general rule, leave a tube in place until:
(5) If you suspect a basal skull or cribriform plate fracture: (1) There is no abdominal distension.
the tube may penetrate into the brain! (2) There is no longer any nausea.
(3) The bowel is active normally, indicated by the passage
PASSING A NASOGASTRIC TUBE. of flatus. If there are only c.400ml gastric aspirate daily,
Lubricate the tip of the tube with a water-soluble jelly. this is the normal volume; if you aspirate ≥750ml, suspect
Sit the patient up and tell him what you are going to do. ileus or bowel obstruction.
Choose the nostril which has the widest channel. If he is
agitated, spray the nostril with lidocaine. Pass the tube CAUTION! Do not remove a nasogastric tube if the
horizontally through the nose. When the tube touches the patient is nauseated, or the abdomen is distended and he
posterior pharyngeal wall, he will gag, so give him a little has passed no flatus, or has >500ml of gastric aspirate od.
water to sip, as you slowly advance the tube. The act of If he has any of these, he probably has paralytic ileus,
swallowing will open the cricopharyngeus and allow the obstruction (12.15), peritonitis (10.1), or an anastomosis
tube to enter the oesophagus. Continue to advance it until that is too narrow. However, if the tube has migrated down
its second ring reaches the nose; its tip should now be in into the duodenum, it will continue to produce large
the stomach. volumes: withdraw it then by 10cm and observe the
effects.
If the tube is too flexible and curls up in the pharynx,
put it in the freezer for 2mins and try again. DIFFICULTIES WITH NASOGASTRIC TUBES
CAUTION! If you are only aspirating through the tube, A patient who is very weak, dehydrated or shocked,
you cannot do much harm, but never start tube feeding may vomit through the act of passing a tube and inhale the
until you are sure a tube is in the stomach. You can easily vomit. If so, lie him on the side, with the head tilted down,
pass a tube into the trachea of an elderly, debilitated, and pass a large stomach tube (Ch30). If he vomits he will
or unconscious patient and drown him with feed. now do so under controlled conditions. Afterwards, pass
To make sure the tube is correctly placed in the stomach: the nasogastric tube.
(1);Aspirate greenish-grey stomach secretions and test
these with blue litmus paper, which should turn red. If pulmonary complications develop, these may partly be
(2);Inject a little air down the tube and listen over the caused by the discomfort of the tube through:
stomach with a stethoscope for a gurgling sound. (1) causing ineffective coughing, and
(3);Listen to the end of the tube. The sound of moving air (2);drying out the mouth by making nose breathing
confirms that the tube is not in the stomach, but is in the difficult.
trachea or bronchi.
If the nasal cartilages necrose (rare), you applied tape
When you are satisfied that the tube is in the right place, unwisely. Pressure is usually caused by an acute
secure it with 2 narrow strips of tape, one on the side and angulation of the tube. A debridement of the dead tissue
the other on the bridge of the nose, extending downwards will be necessary.
on to the tube. In this way you will avoid pressure necrosis
of the alae nasae. If oesophageal erosions develop, you may have been
Connect the tube to a bedside drainage bottle or plastic using too hard a tube. Also, a large tube may allow
bag, to let the stomach contents syphon out. Assist this by regurgitation through the cardiac sphincter and cause an
aspirating. Suck the contents out hourly, or more erosive oesophagitis.
frequently if there is much aspirate, to prevent the tube
blocking. If you cannot aspirate anything, try irrigating the B. OTHER DRAINS
tube with 5-10ml of water; its terminal holes may be Not all wounds need drains, and drains have their risks:
plugged. Never clamp the tube! (1) Bacteria may enter from outside, especially if nursing
care is poor. This risk is small if you use a closed drainage
If the tube fails to decompress the stomach: system.
(1) Its tip may still be in the oesophagus. (2);Bacteria may come from inside a patient and infect the
(2) It may be kinked or blocked. tissues through which the drain passes, particularly the
(3) The stomach may be filled with large food particles. abdominal wall.
(4);Excessive suction may have sucked food or mucosa (3) A drain may erode a vessel or a suture line, especially
into the holes in the tube and blocked it. if you leave it in for a week or longer.
Occasional sips (not gulps) of water will help to ease the (4) A drain may block.
patient’s misery. Keep a fluid balance chart, and as a (5) A drain reduces mobility and so delays convalescence.
general rule replace gastric aspirate by IV 0∙9% saline or (6) A drain may knot itself.
Ringer's lactate.

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INDICATIONS. N.B. There is no evidence to support the use of drains in

(1);To remove blood, serous oozing, or lymph from a the peritoneal cavity to ‘control’ secretions. They block or
loosely confined space (e.g. breast, scrotum, neck, seal off within 24 and 48hrs anyway, unless kept irrigated.
wound): in this case a suction drain is most efficient. Do not to insert a drain unless there is a good reason to do
(2);To drain urine, bile or pancreatic juice, which may leak so. Therefore do not drain all wounds routinely; insert a
from a suture line, or formally to drain the bladder drain when there is a proper indication to do so. Drains
(27.2,6,7,8), gall bladder (15.5), or pancreas. may actually cause the fistula they are trying to ‘control’.
(3);To drain the pleural cavity (9.1): here you need an
underwater sealed drain or special system to prevent air PENROSE FINE RUBBER DRAINS are useful for
being sucked into the pleural space. abscesses. Cut more than an adequate hole in the
(4);To complete the drainage of an abscess cavity: superficial tissues, cut a strip of rubber to fit loosely and
you can let the exudate flow down a tube, or you can let it push this into the depth of the wound (4-14B).
seep away round the edge of a Penrose fine rubber drain. Do not make the hole for the drain so small so that it is
(5);To permit the controlled escape of content from a tight (4-14C). Use a cutting needle to transfix it with a
possibly leaky suture line, for example when you are suture and anchor it to the skin, then tie the ends of the
worried about an extra-peritoneal, i.e. oesophageal or suture several times. When you shorten a drain, you may
rectal anastomosis. be able to leave a loop of suture material securing it.
A safety pin will prevent it slipping inside the
wound, but will not prevent it slipping out.

TUBE DRAINS are useful in large wounds

where you expect much exudate, or in areas of
infection (4-14D). They are especially useful in
the abdomen (4-14E). Have 2-3 sizes of drainage
tubes ready sterilized with suitable adaptors.
Use silicone rubber or polyethylene, rather than
red or latex rubber, which is more irritant.

(1);Try to use a tube drain with a tight seal which

will lead the exudate safely into a bottle, rather
than a piece of rubber which will lead it into
dressings.
(2);Try to place the drain at the bottom of the
cavity to be drained, so that exudate can easily
flow out downwards; make it follow a straight
path.

Fig. 4-14 DRAINS.

A, in a superficial wound pus can drain into the dressings.
B, a corrugated drain should usually consist of several
corrugations and fit loosely through an incision in the
superficial tissues. C, do not push a drain tightly through a
small incision. D, chest drain. E, sump drain. F, draining
the bladder.
G-L, introducing a tube drain into the abdomen.
G, making the incision. H, inserting the 1st haemostat.
I, catching a 2nd haemostat by the 1st and pulling it
through out of the abdomen. J, releasing the
1st haemostat and pulling a drainage tube inside with the
2nd. K, holes cut in the end of the drainage tube. L, drain
sutured in place and the abdominal wall closed.
M, method of fixing the drain so it is held tight.
After Shokrollahi K. A simple method for securing a surgical
drain. Ann R Coll Surg Engl 2005; 87: 388.

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(3);Insert the drain through a separate stab incision, SUMP DRAIN, rubber or plastic. In an ordinary drain the holes through
which fluid is sucked frequently block. A sump drain overcomes this
not through a sutured wound.
difficulty by having 2 tubes, an outer one with many holes in it, and an
(4);If a drain is in any danger of falling out, stitch it in as it inner one through which fluid is sucked. Fluid trickles into the outer tube
passes through the skin (4-14L). and is then sucked away down the inner one. Ideally, suction down the
(5);Keep dressings over the drain separate from the main inner tube needs to be applied with a low pressure pump. There should
also be a single hole in the inner tube close to the surface to prevent too
wound, so the former does not contaminate the latter.
high a pressure building up in the sump. There are many kinds, and you
(6) Do not try to drain the whole peritoneum in peritonitis: may be able to improvise one. A sump drain is particularly useful for
it is impossible anyway. Instead, wash out the peritoneal draining large quantities of fluid from fistulae or a large localized abscess
cavity (10.1). in the peritoneal cavity. Alternatively, use a folded catheter. Suck through
one end and let air enter through the other (4-14E).
(7);Finally, be sure to explain to the ward staff why you
have inserted a drain, how they are to manage it, and when
they are to remove it. DRESSINGS
(8) Make sure, if there is more than one drain, that they are If dressings are in short supply, wash the wound with
labelled appropriately with a permanent marking pen. water 2-4hrly and cover it with a dressing towel (1.11).
Gauze will stick to raw wounds, and paraffin gauze is the
TO INTRODUCE AN ABDOMINAL TUBE DRAIN, standard alternative, but is expensive. You can make your
try to fit a wide bore tube tightly in a small hole. own non-stick dressing with liquid paraffin, coconut or red
Make a small incision in the skin. Use a 10mm (Ch30) palm oil.
tube, and cut side holes in the end. Make a small hole in
the tissues and 'railroad' the drain in (4-14G-J), using a LEAVING WOUNDS OPEN POSTOPERATIVELY,
hand to protect the bowel. Try to do this under direct where you can, is a useful economy. Do this if a wound is
vision! Anchor the drain to the skin with a suture. Insert a not going to discharge. If it oozes a little, put a thin
skin stitch, tie a second reef knot distal to the first one and dressing of gauze or whatever you have on it for 24hrs.
then tie the ends of the suture round the drain with a If you do use postoperative wound dressings,
surgeon's knot (4-14L). Finally, tape the drain to the skin. do not routinely change them unless they are wet, soiled,
Connect it to a sterile bottle. or smelly, or you suspect a wound infection because of a
fever.
SUCTION DRAINS are ideal, especially the disposable
plastic kind. More practical are the reusable 'Redivac' LAYERS OF GAUZE AND COTTON WOOL
suction bottle type, which have disposable drainage tubes. will collect the discharges from a wound which is too
shallow to let you insert a rubber drain (4-14A).
SUMP DRAINS are useful if you have a suction pump and Change these dressings frequently. If necessary, place a
you want to drain fluid, such as urine, or pancreatic juice sheet of plastic or waterproof paper between the outermost
which is welling up from the depths of a wound. layer and the patient's clothes.

THE TIME TO REMOVE A DRAIN varies with the fluid

to be drained. Here are some guidelines:
Blood 48-72 hrs 4.10 Stapling devices
A suspect bowel anastomosis 5-7 days
A septic cavity usually 5-7 days
Bile, pancreatic fluid or urine 10 days A large variety of mechanical devices is available, and you
. may have some to use; do not let them gather dust because
Do not leave a drain in longer than is necessary, because you think they are too sophisticated for you to use!
you run the risk that it may erode a vessel. There is seldom
any need to leave a drain >2wks at the most, except in a (1) SKIN STAPLES.
very large deep abscess. If you remove a drain too early, Skin staples are metal clips with fine sharp teeth at both
pus may build up and seek to discharge itself elsewhere. ends; mount them on a special instrument and lift them off
If a drain is long, shorten it progressively over several days with a toothed dissecting forceps of the correct calibre.
before you remove it. Shorten it by pulling it out, not by Bring skin edges for closure carefully together, apply some
cutting it off. Place a safety pin through it and tape this to tension to straighten the wound and crimp the clip with the
the patient's skin. forceps to hold the edges together. Then repeat the process
moving along the wound.
TUBING, red, rubber sterilizable, 2mm wall, (a) 10mm bore, (b) 15mm
bore. This is multipurpose tubing, the 10mm size is for draining air and Disposable clip applicators exist; these are placed across
blood, the 15mm size is for pus. The firmness of the wall of a drainage the opposed skin edges as above, and fired sequentially.
tube is important. The tube from a chest drain should be firm enough to
ensure an open pathway through the chest wall. The abdominal wall is (2) CIRCULAR ANASTOMOSIS GUN.
less likely to pinch a drain closed, so a firm drainage tube is less
important. If necessary, use a large bore catheter. The first device to staple together bowel was invented by
DRAIN, corrugated red rubber, sheets 1x50x300mm. Pus drains between Russian technicians; the instrument has a safety catch to
the corrugations. Cut the sheets to make drains of various shapes and prevent inadvertent firing. It has a cartridge of 1 or 2
sizes. Do not discard used sheet rubber drains: wash them, boil them, concentric rows of staples mounted on a rod, and an anvil
and store them in antiseptic solution (2.6). For tiny drains, cut up old
intravenous sets or gloves. at the end of the spindle.

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Insert the gun into the lumen of the organ to be (3) LINEAR RESECTION/STAPLER DEVICES
anastomosed, and tie it down with a snug purse-string The linear stapler inserts 4 parallel rows of staples and cuts
suture around the rod over the cartridge; put the anvil between the 2 middle rows; the instrument divides into
inside the lumen of the other organ to be anastomosed 2 parts which can be locked together. Place the separate
and tie another purse-string to hold that end snug. jaws of each half of the instrument inside the bowel
Fix the spindle of the anvil onto the rod of the gun, lumina to be anastomosed, making sure that no excess
and screw them together by turning the end of the handle tissue is inadvertently trapped between the jaws.
of the gun, till the desired point is reached (marked on the Slide the cutting handle down the full length of the 2 jaws,
instrument). This traps the tissues to be stapled between and separate them. This should create a perfect
anvil and cartridge. Release the safety catch, and with one anastomosis; any defect must be closed by hand.
firm movement, pull the trigger. This fires the staples You can then close the remaining open ends with another
across the tissue and simultaneously cuts a central portion linear stapler.
of excess tissue away. Release the trigger, and wiggle the Typical use of the linear stapler is in bowel anastomosis,
instrument out with a gentle twisting movement. e.g. in a right hemicolectomy (11.3) or in a gastrectomy
Unscrew the instrument: you should find 2 complete (13.10)
doughnuts of tissue under the head of the anvil if it has
worked properly. An incomplete ring will mean a defect (4) HAEMOSTATIC CLIPS
exists, which you then need to close by hand. This may be
‘Ligaclips’ are useful for closing blood vessels or ducts
very difficult! deep in the pelvis when ties by hand are awkward because
of limited space; apply the clips double with a special
instrument for better safety.

4.11 Miscellaneous equipment & materials

Some of the humblest equipment is also the most

necessary. Here are many of the things which you should
not be without.

TUBES, rectal, rubber, (a) child's size 8mm (Ch24); (b) adult's size
10mm (Ch30). You can also connect these to a large bore funnel and use
them to give an enema. Introduce them carefully: you can easily perforate
Fig. 4-15 ANASTOMOSIS GUN. the sigmoid colon.
A, safety catch. B, anvil. C, cartridge with staples. D, spindle. CONNECTORS, end-to-end, polypropylene, external diameter
E, screw for approximating anvil and cartridge. F, gauge to measure (a) 4mm, (b) 7mm, (c) 10mm, (d) 15mm, (e) 19mm. Use these to join
adequate approximation. G, firing handle. short lengths of tubing together for suction or drainage etc.
CONNECTORS, plastic 3 way 'Y', assorted sizes.
CLIPS, towel, cross action, 90mm. These are the simplest towel clips.
Typical uses of the anastomosis gun are in colorectal CLIPS, towel, with ratchet, Backhaus. These are more expensive than the
anastomosis (12.10) and oesophageal transection (13.6) towel clips listed above, but they have several other uses, including
holding the sucker tube, and the ribs in chest injuries.
LINEAR CUTTING & STAPLING DEVICES FORCEPS, sponge holding, Rampley, straight, (a) 240mm, box joint.
(b) 120mm. Use these for swabbing, and for ''swab dissection'.
LOUPE, binocular, Bishop Harman, x2 magnification. Perch its 2 lenses
on the very tip of your nose, or wear it over your spectacles. Curl its ear
pieces, so that it fits your face. This is a twentieth the price of a binocular
loupe, and is invaluable for fine operations like repairing nerves,
or arteries, or 'cut-downs', or removing splinters. The disadvantage of a
loupe is that it focuses close to your nose, so use short-handled
instruments.
TROCAR AND CANNULA, straight, with nickel silver or stainless steel
cannula and metal handle, (a) 4mm (Ch12). (b) 8mm (Ch24). (c) 12mm
(CH36). The small size is useful for tapping hydroceles, the middle one
for suprapubic cystotomy, and the largest one for chest drainage.
CANNULA WITH SIDE ARM. Attach suction to the side arm and use it to
aspirate the gall bladder etc. (15.3).
PROBES, malleable, with eye, nickel silver, 150mm, 3 sizes.
Use this to probe perianal fistulae etc.
HERNIA DIRECTOR, Key's. Use this for opening the neck of a hernial
sac.
DIRECTOR, probe-ended, Brodie, 165mm. Use this for exploring
sinuses.
RING CUTTER. Try, before using this, to remove a ring with soap and
Fig. 4-16 LINEAR STAPLING DEVICES used to divide & close string.
bowel. NEEDLES, aneurysm, Dupuytren, (a) needle curving right, (b) needle
curving left. These are curved needles on the end of a handle.
Use them for passing a ligature under something (3-4).

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NEEDLES, aneurysm, small, with blunt point. Keep these in your 'cut (3);If you have enough instruments, particularly
down sets', and use them to pass ligatures under a vein.
haemostats, you can make complete special sets.
CATHETER, metal female.
BRUSH, for cleaning instrument jaws. The jaws and joints of surgical This is the best method, and the one which we follow here,
instruments need brushing regularly. You can also use suede brushes with but it requires many more instruments, and it is very
bronze bristles. important that someone trained puts the right instruments
RAZOR, safety, for preoperative preparation. Shaving a patient
in the sets. If this is not possible, revert to system (1).
preoperatively is not the essential ritual that it was once assumed to be.
You can also adapt a safety razor for skin grafting. Because of the risk of
cross-infection, especially of HIV, these should be disposable. You can do an occasional emergency operation with only
BUCKET, stainless steel, with handles. one general set, but when you have a list of patients to
KIDNEY DISHES, stainless steel, with half curled edges, 4 sizes
operate on, you will need several general sets, if you are
100-300mm.
GALLIPOTS, stainless steel or autoclavable plastic, set of 6 sizes not to wait too long between operations. Boiling a set takes
40-200mm. Use these for lotions, swabs etc. at least 15mins, and autoclaving 30mins. A set costs
JAR, stainless steel with dropover lid, 150x150mm. Use these for spirit between US$750 and US$1000; about 30% is the cost of
swabs.
the haemostats.
JUG, plastic, autoclavable, conical, 3 litre. Stainless steel jugs have
become standard, but plastic ones are satisfactory. If instruments are limited, start by collecting a general set
BIN, soiled. adapted for Caesarean section and laparotomy, and also
JELLY, hydroxymethylcellulose, sterile petroleum jelly. This is a sterile the more important special instruments.
non-greasy jelly for catheters etc.
'BIPP', bismuth iodoform and paraffin paste. This is a mildly antiseptic
self-sterilizing anaesthetic packing material. You can leave it in the nose Once you have all these, try to complete a chest
for a week without significant infection, or much smell (29.6). If you do drainage set, a tracheostomy set, 2 cut down sets,
not have any, smear gauze or bandage with any non-adherent antiseptic and a 2nd laparotomy set. When you have these, your next
ointment.
objective should probably be a minor set for
CARPENTER'S EQUIPMENT (a) Saw. (b) Twist drill. (c) Hammer,
claw head. If you cannot get the surgical equivalent of these, you will such operations as wound repairs and circumcisions.
find these very useful. If you perform many uterine evacuations, 2 or more sets
OTHER MATERIALS include gauze, cotton wool, bandages, adhesive would be useful.
tape, and laparotomy pads (1.11).
A Caesarean Section is only a particular kind of
laparotomy. The set differs mainly in that it includes
2-6 Green-Armytage (or sponge-holding) forceps,
4.12 Instrument sets and the large round-ended Doyen's retractor, which is
specially designed for pelvic operations, replaces
For most operations you will need about 50 general Balfour's. (A wide Deaver or Morris retractor is an
purpose instruments called 'the general set', with a few alternative.)
special ones when necessary. You can handle additions to
the general set in three ways: The sets below mostly start with 6 towel clips and a towel
holder, which you can also use to hold the sucker tube.
(1) You can keep special instruments in the cupboard, and Next come 4 Rampley's sponge-holders, the first 2 of
sterilize them when needed. It is useful for the theatre staff which are used for preparing the patient's skin, after which
that you have cards indicating which instruments you need they can be used to hold towels. The remaining 2 are for
for which operations. If you do not know in advance what 'swabs on sticks', and for swab dissection. Then come
you will need, you can sterilize as many of your basic toothed and plain dissecting forceps, 2 scalpel handles, and
instruments as you can, lay them out on a sterile towelled a heavy and a light needle-holder. There are also 4 pairs of
trolley, and select immediately before each operation what Allis tissue forceps, and various retractors, depending on
you will need. You then cover the trolley with a sterile the set. The expensive items, because of the large number
towel till you are ready for the next operation. Obviously, you need, are the haemostats, straight, curved, big, and
take care not to contaminate the trolley between small, clipped together in groups of 6 on Mayo's pins.
operations. This method has been very successfully used in The more experienced you are, the fewer of these you will
Manama, Zimbabwe, where the sterilizer took the better need. We list 6 of each, which is a generous number for a
part of the day to heat up! beginner. Finally, there is the Pool’s sucker and its tube;
this is a perforated suction tube which does not suck up
(2) You can make incomplete special sets, such as a burr bowel. Do not use haemostats as towel clips!
hole set or an orthopaedic set, with their special
instruments, which you use with the general set when Keep an inventory of equipment and a check list for each
necessary. The advantage of this method is that you will set posted where the set is packed and stored.
have these special instruments ready when needed in a Nice instruments tend to disappear. One aid to keeping
hurry, and you do not waste re-sterilizing instruments not instruments together is to provide them in pairs, or in
required. You can use this method in combination with (1) even- numbered quantities where possible. For example,
and (3); the nurses will find it useful to remember that haemostats
and towel clips should always be in half-dozens.
The theatre is the best place in the hospital for sterilizing
equipment. So try to develop a simple 'central sterile
supply' service which can prepare sets for the wards.

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INSTRUMENT SETS You will want the following sets, some of which ABSCESS SET.
are described elsewhere: a uterine evacuation set (2 if possible), a general 2 Rampley's sponge-holding forceps.
purpose set (preferably 2 sets), a Caesar set, a cut down set, an abscess 4 towel clips.
set, several minor set (for hernias, etc.), an orthopaedic set (for drilling 1 knife handle.
for osteomyelitis, etc.), an intestinal clamp set (for resecting bowel), 1 sinus forceps.
a fine instrument set (for hand surgery), an eye set (28.1), a burr hole set, 1 Mayo's scissors.
a chest drain set, and a tracheostomy set. 1 toothed dissecting forceps.
1 150mm receiver,
SHARP EQUIPMENT needs to be kept separately, because it gets blunt 2 gallipots and some gauze swabs.
if it is autoclaved too often. Keep scissors separate from other 2 towels.
instruments. Keep osteotomes and gouges in a cupboard and put them in
sterilizing fluid 30 minutes before you use them. Autoclave the bone saw UTERINE EVACUATION SET.
when you want it. Keep the bone drill and the twist drills to go with it in a 2 ovum or sponge-holding forceps (without ratchets).
special sterile pack. 1 Sims' vaginal speculum.
1 vaginal speculum (Sims, Auvard’s or Collin’s).
CAUTION! Always re-autoclave the packs and drums regularly. 2 Teal's vulsellum forceps.
A pack which has not been re-sterilized for some time is a risk, especially 1 set of Hegar's dilators.
if it is only covered in towels. You may find termites inside it! Karman suction curettes
Uterine curettes with sharp and blunt ends (several sizes each).
THE CONTENTS OF PARTICULAR INSTRUMENT SETS 1 200mm Kocher's forceps.
1 toothed dissecting forceps.
THE GENERAL SET (including the instruments for laparotomy) Have intra-uterine contraceptive devices (IUDs) available.
6 towel clips.
1 Backhaus towel forceps. ORTHOPAEDIC SET.
4 Rampley's sponge-holders. 6 towel clips.
1 toothed dissecting forceps (Treves). 4 Rampley's sponge holders.
1 plain dissecting forceps (Bonney's). 4 dissecting forceps: (1 heavy toothed 180mm Lane's or Charnley's,
1 #4 & 1 #5 scalpel handle. 1 light Adson's 125mm, 1 plain 180mm, 1 McIndoe's 180mm).
2 needle-holders, a heavy and a light. 6 curved 150mm Spencer Wells haemostats.
2 Allis tissue forceps. 6 curved 200mm Spencer Wells haemostats.
2 Lane's tissue forceps. 1 # 4 & 1 # 5 scalpel handle.
6 200mm curved haemostats (Spencer Wells). 4 220mm light bone levers, Lane's or Trethowen's.
6 120 or 140mm straight haemostats (Halstead's or Crile's). 4 275mm heavy bone levers.
6 120 or 140mm curved haemostats (Halstead's or Crile's). 1 Faraboef's elevator.
2 Kocher's artery forceps. 1 large & 1 small periosteal elevator (for the femur and humerus).
2 Czerny's (or Langenbeck's) retractors. 1 Size C double-ended Volkman's bone scoop.
2 Morris' retractors. 1 350g mallet.
Poole's sucker tube. 1 sequestrum forceps.
1 20cm receiver & 2 gallipots. 1 180mm Read Jensen bone nibbler.
Desirable additions include Lahey's curved gallbladder forceps. 1 bone file or rasp.
1 220mm Liston's bone cutters.
CAESAR SET (US$950). 1 200mm bone hook.
6 towel clips.
1 Backhaus' towel forceps. BURR HOLE SET.
4 Rampley's sponge holders. 1 Hudson's standard perforator 12mm.
1 18cm toothed dissecting forceps. 1 Hudson's set of conical burrs 13mm and 16mm.
1 18cm plain dissecting forceps. Hudson's brace.
2 #4 scalpel handles. 1 West's self-retaining retractor.
2 180mm needle-holders. 1 60mm brain sucker.
2 Allis tissue forceps. 1 Ch14 soft rubber catheter.
6 Green-Armytage forceps. 1 20ml syringe for washing out.
12 150mm straight Spencer Wells haemostats.
6 230mm curved Spencer Wells haemostats. SMALL (Hand) INSTRUMENT SET.
1 Morris retractor. 2 small sponge holding forceps.
1 Doyen's retractor. 1 plain 150mm McIndoe dissecting forceps.
Poole's sucker and tube. 1 plain 100mm Silcock's ophthalmic dissecting forceps.
1 300mm bowl (for blood clot), 1 toothed Adson's 120mm dissecting forceps.
1 200mm receiver & 2 gallipots. 4 165mm Gilles skin hooks.
Desirable additions include a tenaculum, and a self-retaining retractor. 1 light 190mm McIndoe dissecting scissors.
1 light 140mm curved Aufrecht's scissors.
MINOR SET (US$750). 12 curved Crile's mosquito haemostats.
6 towel clips. 1 Bard Parker # 4 scalpel handle.
2 Rampley's sponge holders. 2 114mm Derf needle holders. 2 small 178mm Meydering retractors.
4 Backhaus' towel forceps. 2 114mm Harlow Wood tendon hooks.
1 # 4 & 1 #5 scalpel handle. 1 small curette.
1 toothed dissecting forceps (Treves). 2 assistant's scissors.
1 plain dissecting forceps (Bonney's). 1 fine probe.
4 Allis tissue forceps.
1 West's self-retaining retractor. KIRSCHNER WIRE PACK.
2 Czerny's retractors (or Langenbeck's). 6 wires of each size 0∙75mm, 1∙0mm, 1∙5mm.
12 125mm curved haemostats (Spencer Wells). 1 Pulvertaft's Kirschner wire introducer.
6 200mm curved haemostats (Spencer Wells). 1 pair of Kirschner wire cutters.
1 20cm receiver 7 2 gallipots.
Desirable additions include a dissector and a Volkmann's spoon.

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Many trauma victims are HIV+ve, but their management

5 The impact of HIV should proceed along standard lines regardless.
Indeed surgical intervention may buy a patient valuable
on surgery time before his or her eventual demise, and indeed alleviate
that process.
“One night after I had been doing some blood tests in a rural area with some
Consequently examine the impact of surgical intervention
local medical colleagues, they went off with some girls from the town.
They slept with them, and only one of them used a condom. In the morning I in certain HIV-related states carefully, and question the
asked them how they could possibly have taken such a risk, since we all knew standard practices of surgical orthodoxy in relation to HIV
the prevalence of HIV was quite high in the region. They laughed, saying that disease.
you couldn’t give up living just because you might get a disease.”
A research worker in Central Africa, PANOS Dossier, 1987 (March).
Consider performance status and life expectancy carefully.
This is especially true in those parts of the world where
HIV prevalence is high but where testing is irregularly
5.1 Introduction available, and where their HIV status is generally not
known by patients themselves.
SURGICAL OVERVIEW Avoid elective surgery (especially in patients with clinical
Since the dramatic appearance of a completely new and signs of immunosuppression) in the following (unless you
growing range of pathologies in 1981, and the identification of can guarantee close supervision of effective anti-retroviral
the Human Immunodeficiency Virus (HIV) in 1983 by (ARV) therapy and a count >200/μl):
Françoise Barré-Sinoussi, Luc Montagnier and colleagues at (a).cosmetic procedures, especially on the nose and
the Institut Pasteur in Paris, enormous efforts have been made mouth, including routine circumcision
to combat this new disease but with only limited success in (b).complex plastic surgery, especially free flaps
many developing countries. The reasons are complex and vary (c).neonatal intervention for complex abnormalities
in individual countries, but poverty and lack of resources are (d) open brain surgery
the biggest drawbacks. (e) tonsillectomy
(f) open thoracic surgery
In these environments, HIV-related disease continues to worry (g) open perianal surgery
medical resources and presents one of the greatest single (h) insertion of prosthetic grafts or metal
challenges to the medical practitioner seeking to alleviate
suffering in the developing world. As a result, the practice of Note that after surgery, you often cannot re-start ARV
surgery cannot ignore the impact of HIV and must assess the therapy immediately, and this may be a problem (5.8).
implications of this new disease. Although much has been
written of HIV-related surgical pathology, the preponderance Whilst this list is not exclusive, it is also not exhaustive;
of the literature reflects the experience of surgeons working in treat each individual case on its merits. Nonetheless,
well-equipped hospitals in the First World, where HIV within a broad perspective, exercise great caution in the
prevalence is low, and where there is ready access to a above types of surgery. Post-operative infection rates are
multiplicity of laboratory testing, drug therapies and nursing doubled in asymptomatic HIV+ve patients, and more than
back-up. From personal experience we try to give you trebled in symptomatic HIV+ve patients, especially where
guidelines to help you in this new medical mine-field. the CD4 count is <200/μl.
The practice of surgery is everywhere a challenge, and is so HISTORICAL OVERVIEW
especially in the developing world where improvisation often is The most compelling evidence to date suggests that HIV
the order of the day. Be sure therefore to consider the balance was transferred to humans through transformation of an
of risk inherent in any surgical procedure. An operation which almost identical simian (monkey) virus in the Congo region
is seen as routine in a well-equipped teaching centre may be a in the 1940s or 1950s. The oldest +ve HIV test is from a
serious risk in a rural hospital; likewise an operation serum sample of an adult male in Kisangani (formerly
traditionally considered routine in an environment of low HIV Stanleyville), Congo, taken in 1959. Before that there were
incidence may prove to have great risk where HIV is common. no deep freezers to store serum. Another +ve sample was
You must not underestimate complications expected in HIV found in a lymph node from Congo in 1960.
patients, particularly those not on treatment, and once a
commitment is made to surgical intervention, you must treat The emergence of certain diseases, such as Kaposi sarcoma,
these complications aggressively if they arise. Thus you may amongst the homosexual community and intravenous drug
need to restrict your elective surgery, particularly in certain abusers in the USA in the late 1970s brought to light a
anatomical regions, considering that HIV disease is series of ailments related to immune deficiency.
progressive. Subsequently, an infective agent, one of a group of
retroviruses, was identified, and positively linked to further
Nonetheless, do not deny emergency surgical intervention to conditions, especially a wasting syndrome seen in Central
the HIV patient, who often requires more aggressive and Africa, known as Slim Disease.
urgent resolution of sepsis.

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It was then evident that HIV was spread heterosexually and 5.2 Pathophysiology
that subsequently this mode of spread was to prove
geographically and numerically far greater a threat to The causal agent of AIDS is known to be HIV which has
populations. The rate of spread is linked to the presence of two known types (HIV-1 and HIV-2), belonging to the
co-existent sexually-transmitted diseases, principally of the family of primate lentiviruses (slow viruses), differing by
ulcerating variety. the former having a vpu and the latter a vpx gene, absent in
the other. There is great similarity with the Simian
Studies show that a relatively small pool of infected Immunodeficiency Virus (SIV) strongly suggesting a link
commercial sex-workers could be responsible for 80-90% of between these viruses. HIV-2 is more similar to SIV, and
the initial disease prevalence in a community. HIV-1 has been found genetically to originate from a
Numbers of cases of HIV disease have increased exponentially, chimpanzee species. In conformity with other retroviruses,
and in many sub-Saharan countries doubled every 9-12months. HIV contains a virus capsid whose hallmark is the enzyme,
This trend has been followed in Southeast Asia and the Indian reverse transcriptase. This enables a double-stranded DNA
subcontinent. copy of the original genomic RNA to be made in host cells.
The viral DNA is thus integrated into the lymphocyte
Initial reactions amongst politicians to the scourge of HIV, genome. The glycoprotein (gp120) envelope of HIV binds
which was known to result in inevitable, usually slow and to the glycoprotein (gp41) molecule on the surface of
agonizing death through an end-stage described as Acquired certain thymus-derived T-lymphocytes known as
Immune Deficiency Syndrome (AIDS), was to deny the helper/inducer cells. This molecule called CD4 is also
problem. The overlay of sexual promiscuity, and in the West, found on other cells, such as macrophages, monocytes,
of weird life-styles, served to exceptionalize HIV disease, and even some antibody-producing B-lymphocytes, as well
which has been handled differently from other infectious as in brain cells.
diseases (especially with regard to counselling). Stress was on
confidentiality and anonymity and concerns about abuse of a The helper/inducer T-lymphocytes are the kingpins of the
victim’s civil rights demanded private individual counselling immune response: when stimulated by antigen contact, they
prior to HIV testing. This has resulted in isolation of the divide and produce lymphokines (such as interleukin 2 and
sufferer, contrary to the prior tradition (as in Africa) of interferon) which control the growth and maturation
understanding illness as a community problem to be discussed particularly of cytotoxic/suppressor T-lymphocytes which
fully within the family and then within the village setting. have a CD8 glycoprotein molecule.

Thus the HIV patient has often been secluded and even The ratio of CD4 to CD8 gives a good indication of
victimized in rural society and even within the family itself. immunological capability. Early on in HIV infection, the
Many women preferred not to know their HIV status, fearing CD8 cell number may rise, but there is an inexorable fall in
ostracization, because they have little control over their lives CD4 cell numbers; in the final stages of disease, the CD8
and cannot make plans for the future. With the increased count will also fall.
availability of anti-retroviral medication however,
the exceptionalization of HIV disease has become an Virus replication appears to occur mainly in dividing CD4
anachronism. cells and these cells divide upon stimulation by
In some countries, notably Uganda, the inexorable increase of micro-organism antigens (at least in vitro): thus intercurrent
HIV cases seems to have been reversed, principally through infections may stimulate viral replication. Paradoxically,
strenuous saturated educational coverage, propagated in the in the final stages of the disease, when CD4 counts
main by non-governmental organizations, and by popular fear approach zero, there may be little active viral replication.
of the disease. You can think of the CD4 count as the distance a patient is
from death; the viral load the speed with which he is
The advent of ARV therapy has had a significant impact on travelling there.
HIV disease, even in the late stages. However, this therapy
remains exorbitantly expensive long-term for most people in The extensive genetic variability in HIV isolates and the
developing countries, although WHO is making strenuous inherent difficulty of blocking the CD4-HIV binding make
efforts to make low-cost drugs available. Single-dose vaccine development far from straightforward.
treatments for antenatal women reduce transmission to the
unborn child, after needle-stick injuries, and in rape cases. The Although HIV core antigen can be detected and viral counts
emergence of resistant strains, however, remains a problem. are very useful for monitoring anti-retroviral therapy, these
The development of a vaccine is still at this stage a dream. tests are rarely available in the developing world. The most
Viricidal creams may offer some real hope in reducing widely used ELISA anti-Immunoglobulin antibody test for
transmission. HIV infection will only become +ve 6wks to 9months after
infection, thus producing a ‘window’ period when HIV is
Thus HIV is a fact of life (and death) in the developing world, actually present in serum but not detected.
and surgeons working there must know its implications.

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This has serious clinical significance; change in the test from The risk increases in a violent sexual encounter such as
-ve to +ve is known as seroconversion. The accuracy of the test rape, in the deflowering of a virgin, if ulcerative venereal
and its sensitivity is high; most incorrect results arise from disease is present (up to a factor x10), if non-ulcerative
laboratory or deliberate errors, and if a result is clinically venereal diseases are present, if an intra-uterine
suspicious, you should organize a repeat test, preferably using contraceptive device is in situ and during pregnancy.
a different laboratory or a different technique (viz. radio- It may be 500 times higher in the phase of acute HIV
immunoassay) with better specificity. The Western Blot seroconversion. The risk increases x4-x7 in anoreceptive
method is expensive, however, and is probably not justifiable intercourse, and is further increased when jelly with the
in most situations in the developing world. spermicide, nonoxylon-9, which breaks down the rectal
lining, is used. The risk is also present in oral sex, and with
artificial insemination.

5.3 Transmission & prevention A condom (female as well as male) is protective, and
reducing menstrual bleeding (by use of the combined pill
and depot medroxyprogesterone acetate) will also reduce
The 3 most prolific methods of transmission of HIV in the transmission. Male circumcision also reduces transmission.
developing world are:
(1);by sexual contact, dominantly heterosexual, Restricting sexual activity to a monogamous marriage
(2);from mother to baby, without extra partners remains the only certain way to avoid
(3);by blood products. HIV exposure by this route. Therefore you should advocate
prenuptial HIV testing, and certainly before any pregnancy
Transmission may also occur through is considered.
(4) transplanted tissue,
(5) sharps injuries and splashes. (ii) Vertical transmission of HIV from mother to baby
This may occur between drug users sharing injection needles, varies between 15-45% if there are no interventionist
especially when ‘mainlining’ (injecting) themselves with IV strategies used; estimates are that transmission occurs in
drugs. Viral particles have, however, been detected in seminal ⅓ before delivery, in ⅓ during delivery, and in ⅓ after
fluid, and pre-ejaculate fluid, vaginal and cervical secretions, delivery. It seems possible to reduce transmission to 2-3%
breast milk, tears, urine, and saliva, so caution regarding with the antenatal use of antiretroviral drugs (a single dose
transmission is wise. of nevirapine appear to be sufficient), arranging delivery by
Caesarean section, and avoiding mixing breast feeding with
(i) Sexual contact. bottle feeding of milk substitutes.
As simultaneous sexual promiscuity by men is common, there
can be no clearly defined risk group; nonetheless certain Whilst the adoption of mandatory Caesarean section for
groups have significantly higher prevalence rates than others, HIV-mothers may have theoretical justification,
and therefore a high index of suspicion is justified. the morbidity and mortality inevitable in such a policy in
Such groups are: the developing world outweigh the advantages
army personnel, notwithstanding the costs of screening and surgery.
those travelling widely in their employment, Previous policies of restricting breast-feeding have actually
e.g. truck-drivers, police, and itinerant salespersons, been shown to be harmful, and are not recommended.
attenders at venereal disease clinics, especially when tested
+ve for syphilis, Other practices, however, reduce risks of transmission:
men working away from home, protocols developed to prevent blood exchange from foetus
those with high alcohol intake, (low-pressure) to mother (high-pressure) in potential rhesus
male prisoners (through forced rape), sensitization are applicable up to the moment you clamp the
divorced, separated, or young widowed women, umbilical cord:
young widows and widowers. (1).Treat infections which disrupt the placental barrier,
particularly malaria and toxoplasmosis because these
As, however, the spouses of infected persons are at as great increase transmission of the virus. Malnutrition also allows
risk, the identification by history and direct social questioning increased transplacental viral transmission.
of potential HIV individuals becomes at best difficult and (2).Reduce prolonged labour by use of prostaglandins and
time-consuming. Nonetheless identifying a girl as a virgin is oxytocin. Treat chorio-amnionitis with antibiotics.
helpful in minimizing HIV as a factor in reaching a diagnosis. (3).Avoid external cephalic version and amniocentesis;
clamp the umbilical cord as early as possible.
The estimated risk factor of transmission from a seropositive The longer the baby is protected in labour from direct
man to woman during a single unprotected sexual exposure is contact with the mother’s blood and secretions the better.
c.0∙5-0∙75%, but seropositive woman to man 0·25%. (There is (4).Avoid artificial rupture of membranes and make
a considerable range from 0·1% where the viral load is <1700 episiotomies at the last moment. If membranes are already
copies/ml to 20% where the load is >38500/ml). ruptured, reduce contact time by use of oxytocin.
The risk is zero if viraemia is undetectable.

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N.B. Foetal scalp electrodes and foetal scalp blood Use blood transfusion therefore very sparingly; educate
collections are contra-indicated. anaesthetists concerning the safety of working with
suboptimal Hb levels, and learn the appropriate strategies.
(5).Be very careful with instrumental deliveries, preferably Various strategies can avoid risks:
using rubber cup vacuum extractors to prevent abrasions of the (a) Autologous blood.
foetal head; better avoid them altogether. Washing of the Take 1L of blood from an adult; treat him with maximal
vagina with povidone iodine before instrumental delivery or doses of ferrous sulphate for 2wks; then take a further 1lat
after rupture of membranes is probably a sensible precaution. the same time as transfusing 500ml of the previously
Rinse babies immediately after delivery in warm water. collected blood. In this way you can prepare 1500ml
(6).During Caesarean Section, try to deliver the foetus with (3 units) of blood for elective surgery.
intact membranes; do not use the scalpel to open the whole
thickness of the abdominal wall, lest the baby is cut. (b) Intraoperative haemodilution.
Suctioning of the baby after delivery pushes maternal blood up Take 1lof blood immediately prior to surgery and replace it
its nose and is unnecessary; wiping is usually sufficient. with crystalloid. The fresh and platelet-rich blood is then
immediately available for re-infusion if needed;
Transmission during breast feeding appears to increase if the blood viscosity is also incidentally lowered and this may be
mother seroconverts during this time, if breast feeding is mixed an advantage, especially in vascular surgery.
with other feeds, and if the nipple is cracked or eczematous, or
the baby has mouth ulcers. Abandoning breast feeding implies (c) Peroperative blood salvage (Autotransfusion).
the ready availability of milk substitutes, rarely the case for the Blood from clean traumatic injuries of the chest or
poor in low-income countries, and removes the natural abdomen, or from an ectopic gestation, is ideal for this
transmission of protective immunoglobulin to the baby. treatment; it can be life-saving. Also, it carries no risk of
However, expressed breast milk can be pasteurized (kept at hepatitis or HIV, and it will be perfectly cross-matched.
62·5°C for 30mins, or heated just up to boiling and then Autotransfusion is thus very useful.
cooled) to eliminate HIV, as well as Hepatitis B virus (HBV).
Supply it then in a small cup rather than in bottles with teats as CONTRAINDICATIONS.
these are difficult to sterilize properly. Nutrients and Do not attempt autotransfusion if:
micro-nutrients are preserved but IgA antibody activity is lost, (1).There is an offensive smell when you open the
and diarrhoea is then a frequent problem. Proper attachment of abdomen.
the baby to the breast and preventing nipple damage also (2) The abdomen is grossly contaminated.
reduces the risk. Heat treatment is not possible for colostrum, (3) The blood is obviously haemolysed.
however, because it curdles and there is a high viral load in (4) A woman is more than 14wks pregnant with a ruptured
colostrum. amniotic sac. (Her blood will be contaminated with
Correct Vitamin A deficiency, which increases the risk of amniotic fluid containing large quantities of
transmission. thromboplastin. If you transfuse this, it could theoretically
N.B. Transmission of HIV from seropositive baby to cause disseminated intravascular coagulation (DIC).
surrogate breast-feeding mother has occurred, and vice versa Nonetheless you can use blood in a contaminated peritoneal
from seropositive surrogate mother to baby. cavity on occasion under antibiotic cover without untoward
effect if you are absolutely desperate.
(iii) Transfusion of blood products entails a significant N.B. The presence of fresh clots is not a contraindication
risk (3.6), especially where laboratory testing is unreliable. to autotransfusion.
Because of the window period, apparently safe blood products
may actually be contaminated. In order to reduce this risk, THE VACUUM BOTTLE METHOD is the best.
encourage long-standing donors whose HIV-ve status Buy vacuum bottles, or prepare them by
can be followed over a considerable period of time closing blood-taking bottles containing 150ml 3·8%
(and are therefore unlikely to seroconvert), unlike citrate-dextrose immediately after they have been sterilized,
schoolchildren who may become newly sexually active. before the steam in them has had time to condense.
Discard blood from a new donor deliberately; accept it only if Clamp a taking set, introduce one of its needles into the
he tests -ve on a subsequent visit after nine months. Select abdomen, as if you were doing a 4-quadrant tap, and then
blood donors on a voluntary basis, thus removing a financial put the other needle into the bottle and remove the clamp.
incentive for donation. To fill the bottle insert another sterile needle connected by
way of a heparinized suction catheter to a vacuum pump
The risks from transfusion are cumulative, rising with numbers into the bung. You may be able to collect up to 3lof blood
of units transfused. Furthermore the risk of using products this way. If the vacuum is imperfect, and does not fill the
pooled from many donors is also higher; thus do not use Fresh bottle, apply suction with a vacuum (water) pump
Frozen Plasma and pooled Platelet Concentrate. The use of connected to a sterile needle inserted through the bung.
Factor VIII concentrate is likewise risky but may be essential
in treatment of haemophiliacs requiring surgery; render it safe
by heat treatment.

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There are expensive commercial autotransfusion machines

available, but they all work on the system of (1) aspirate,
(2) anticoagulate, (3) filter, (4) centrifuge, (5) wash,
(6) re-infuse.

N.B. Directed blood transfusion (where blood is collected

from relatives or friends) has almost all the pitfalls of
undirected transfusion.

(iv) Transplantation (of kidneys, allograft skin etc)

carries the risk of HIV transmission.

(v) Sharps injuries and splashes.

Risks of transmission of HIV to health personnel are small
but real. Use routine double-gloving for surgical
procedures, especially when you may encounter sharp
pieces of bone, or use wires, drills or chisels; some prefer to
use a glove half a size greater on the outside. The use of
different coloured gloves may highlight damage to the
glove material more easily. Wear a non-sterile glove under
a sterile one if economy dictates. (Do not use recycled
gloves for operating, except as the first in double-gloving,
unless economy dictates!). Long arm gloves are useful for
surgery involving deep ingress into the abdominal cavity.
Special Kevlar gloves are useful (and re-usable) as the
interior glove because they cannot be penetrated by needles
or blades: this makes their initial high cost worthwhile.
They are however cumbersome to work with. Sterile cotton
gloves can be worn outside the latex glove where wires are
Fig. 5-1 AUTOTRANSFUSION using a funnel. This is also useful if the used in Orthopaedic surgery; the wire will snag on the
patient has a ruptured spleen. Use 6 large pieces of gauze, and collect the
blood through a blood-giving IV line into an empty citrated cotton before tearing the latex.
blood-collection unit.
Kindly contributed by Stephen Whitehead of Maua Hospital, Kenya. Blood splashes are also important especially to the open eye
(with risk rates estimated at 1·5%). Use protective eye-wear
THE SOUP LADLE METHOD is less satisfactory, therefore, especially where spraying is likely,
but is useful when you cannot use a vacuum bottle because e.g. orthopaedic drilling. However, wrap-around plastic
there are too many clots. Keep the equipment (5-1) ready goggles are inconvenient for those with spectacles, and
sterilized. Put the patient into 15° head-down position, attachment of sides to the spectacles is a reasonable
make a small opening in the peritoneal cavity to begin with, alternative. Masks also help protect the mouth from
and be prepared to catch the blood, as it escapes, with a splashes.
sterilized stainless steel soup ladle or gallipot. Then complete
the incision and ladle out the rest of the blood. Careful operating is, however, probably more important
The right hypochondrium may be the easiest place to collect it. than trying to prevent injury. Avoid operating if possible
Pour it through a small metal funnel, and collect it through a when you are over-tired! Likewise drug users can avoid
blood-giving set into empty blood transfusion packs HIV transmission by using unused sterile needles,
pre-primed with citrate anticoagulant. The filter in the drip set and discarding these carefully.
will remove smaller clots.
N.B. You can also use a filter made of 6 layers thicknesses of The estimated risk of seroconversion with a penetrating
gauze but beware that if the gauze is contaminated by glove hollow needle-stick injury is 0·3% and with a solid needle
powder, the autotransfused blood may kill the patient! is 0·03%. Reduce the use of cutting needles (you can close
You can also squeeze blood out of soaked laparotomy pads an abdomen readily using a blunt-ended needle) and
after they have been agitated in saline. preferably employ a no-touch surgical technique. Introduce
Alternatively, you will find a sump useful. This is a conical rigorous adoption of theatre routines: do not hand sharps
vessel with a handle and holes towards its tip. Insert it deep in from scrub-sister to surgeon and vice-versa. Create a
the abdomen; blood will flow in through the holes and can be neutral zone where sharps are placed in a receiver by only
sucked out. one person at any given moment. Do not use hands as
CAUTION ! retractors, and the surgeon’s fingers to guide needles (2.3).
(1).Either transfuse the blood immediately, or throw it away. Draw up multivial solutions using an unused sterile needle.
(2) Do not use it for someone else. Glove up for venepuncture and handling blood samples.
(3) Use prophylactic antibiotics

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Most injuries to health-care workers arise from careless Adopt a hospital sharps-injury policy in order to advise all
handling of sharps: health workers on precautions and action to take after
exposure, depending on facilities available. Discipline staff
Recapping of needle 40% not taking precautions. Introduce a post-exposure
Improper disposal of sharps 32% prophylaxis/treatment policy if you don’t already have one
Contamination in open wound 25% in your hospital. Remember to wash the part injured by a
Other 3% needle-stick immediately, and cleanse it with betadine.
Use the low-cost de Montfort medical waste incinerator.
In the laboratory, heat-treat serum at 56ºC for 30mins
before testing; pipette solutions using a teat not your mouth!

A practice that assumes every patient is a HIV risk, and

all blood may be contaminated, is likely to result in far
fewer accidental seroconversions than one that attempts to
identify individual high-risk patients.

The HIV+ve health worker is extremely unlikely to

transmit HIV to patients except sexually; the risk of a
surgeon passing HIV to a patient has been estimated at
1:800,000.

5.4 Sterilization
Wear gloves when cleaning spills. Dilution by washing is
important. If alcohol is used, wipe the surface several times
because alcohol evaporates. Establish the rule,
“You spill it, you clean it.”
Dispose contaminated materials safely; do not put them on
a rubbish tip where they may be scavenged!
Ordinary laundry is effective for cleaning soiled linen after
thorough soaking.

Chemical disinfection is acceptable only for instruments

such as endoscopes which cannot tolerate heat. Pull out
and clean light carriers and biopsy carriers, and wash
internal tubes thoroughly before placing them in antiseptic.
These may be:
Fig. 5-2 LOW-COST SHARPS CONTAINER WITH
(a) Chlorine-releasing solutions
NEEDLE REMOVAL DEVICE. * (readily neutralized by blood or tissue),
A, Ordinary plastic bottle. B, Bottle tops. C, Bottle top with hole cut out. (b) Ethanol 70% (for 15mins):
D, Syringe inserted through hole and needle eased off inside bottle. (higher and lower concentrations are less effective),
After Onayade AA, Omotoso AO, Olafimihan VB. Hospital biohazard control:
low-cost device for safe collection and disposal of hypodermic needles.
(c) Isopropyl Alcohol (2-propanol) 70% (for 15mins),
Tropical Doctor (2006):36(4)215. (d) Povidone Iodine 2.5% (for 15mins),
(e) Formaldehyde 4% (for 30mins),
Discard needles uncapped; separate and dispose of other sharps (f) Alkaline-buffered Glutaraldehyde 2% (for 10mins)
(do not leave them for someone else) in a dedicated, labelled, (Cidex,Asep,Omnicide Tegodor) effective for 14days,
non-breakable, puncture-proof, watertight container with a once prepared, if kept away from direct sunlight,
keyhole opening large enough but too small to admit a hand. (g) Hydrogen Peroxide 6% (for 10mins),
Fix this to a wall, and empty it when ¾ full, and incinerate it. (h) Virkon (balanced blend of peroxygen compounds,
Do not over-fill the container. (You should probably avoid surfactant and organic acids in inorganic buffer at
expensive specially manufactured containers as they may be pH2.6, sold as a stable powder, is non-corrosive,
utilized for another purpose by cleaners). A useful home-made non-bleaching, non-toxic and not a transport hazard:
container can be made from an ordinary mineral water bottle a fresh 1% solution is used for 30mins).
with its screw-top pierced with an elliptical hole (5-2A); thrust
a needle attached to a syringe through this hole and with CAUTION!
minimal manipulation pull the syringe back, thus detaching it The following solutions are NOT recommended: Spirit
from the needle (5-2D). Put non-sharps in other containers in Solutions <70%, especially <50%, Cetrimide (Cetavlon) or
order not to waste the space in the sharps container; Chlorhexidine (Hibitane), Formalin 0.1%, Quarternary
do not separate needles from syringe with your fingers! Ammonium Compounds (e.g. Dettol, Roxenol, Flavine etc).

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* Chlorine-releasing solutions are excellent disinfectants. As most erroneous results are from laboratory errors rather
Their power is expressed in ‘available chlorine’: 1% = 10g/l = 10,000 ppm
than deficiencies of the test, repeat surprise results.
(part per million) = 3·33 chlorometric degrees
N.B. Chlorine corrodes iron and stainless steel, so these disinfectants must Repeat confirmation of -ve results likewise for safety,
not be stored in stainless steel containers; equipment is easily corroded and after 3-6 months. Oral tests are now available.
should be rinsed well after disinfecting.
Sodium Hypochlorite solutions (Liquid bleach, Javel) are unstable:
Though the theoretical model of insisting on counselling for
Neat disinfectant (domestos, Chloros, Sterite) contain c.100,000 ppm
Strong hypochlorite solution BP contains >80,000 ppm HIV tests as promoted in the First World is commendable,
Most supermarket brands contain c.50,000 ppm it may not be practical in the developing world situation
Milton contains c.10,000 ppm where resources are few and trained manpower limited.
HIV is inactivated by 5,000 ppm solution in 1 minute, by 50ppm in 10mins;
It has been shown that a short description of the facts of
at this low dilution it is very unstable so must be freshly made, used and
discarded. HIV disease without full discussion of the social
Calcium Hypochlorite (70% available chlorine) and Bleaching Powder implications will lead to fear and despair rather than a
(35% available chlorine) sold as tablets, granules or powder, both decompose positive attitude to the disease; thus limited counselling
gradually if not protected from heat and light.
may be more detrimental than none at all.
Sodium Dichloroisocyanurate 0·5% (NaDCC: 60% available chlorine) and
Tosylchloramide sodium (Chloramine T: 25% available chlorine) sold as
powder or tablets, are comparatively stable. If tests are only done when a patient has been fully
Use solutions of 1,000 ppm for general disinfection of wards, theatres and counselled, many patients will go untested. Furthermore a
laboratory benches.
possible HIV-ve result may thus be denied a patient who is
Clean contaminated surfaces with 5,000 ppm which is left in contact for
30mins before rinsing off. too scared to ask for a test, assuming as many do in areas of
high HIV endemicity, that any severe illness is probably the
Recommended dilutions of chlorine- releasing agents dreaded disease that leads to certain early death.
To put pressure on a patient to make up his mind on
Available Clean Dirty condition
Chlorine condition (e.g. blood spills, whether or not to have a test which may reveal a fatal
(e.g. cleaned soiled equipment) illness is like asking a patient with a pathological fracture
medical whether he wants an X-ray to be done if it might reveal a
equipment) malignancy. Indeed even the counselling becomes
Available 0·1% (1g/l, 0·5% (5g/l,
Chlorinerequired 1000pcm) 5000pcm)
something with a stigma attached for the patient.
Dilution
Sodium 5% 20ml/l 100ml/l In areas of high endemicity, an HIV test may be important
Hypochlorite to exclude HIV infection as a diagnosis, rather than
Solution confirming the presence of the disease, and thus giving a
Calcium 50% 1·4g/l 7·0g/l
Hypochlorite
patient hope when he had long given up ideas of recovering
NaOCC 60% 1·7g/l 8·5g/l from illness.
NaOCC-based 1·5g 1 tablet/l 4 tablets/l
tablets per tablet Where HIV is prevalent, and testing difficult or
Chloramme 25% 20g/l 20g/l impossible, an awareness of the clinical presentation of
RECOMMENDED DILUTIONS OF DISINFECTANTS HIV-related disease is essential. As any body system can
WHO AIDS Series (2), Guidelines on Sterilization and High-Level Disinfection be affected; HIV does not manifest itself usually by a single
Methods effective against HIV. Geneva 1988 identifying pathology. Therefore look for the usual
significant tell-tale signs in patients, especially to give clues
Standard autoclaving at 121ºC at 1 kg cm2 or use of a hot air as to the underlying pathology of the presenting condition.
oven at 170ºC for 2hrs eliminates HIV (as it does the hepatitis HIV has made new diseases common, and changed the
B virus, which is much more easily transmitted). diagnostic spectrum.
Thus place all surgical instruments which tolerate heat, and all
reusable surgical sundries in disinfecting fluid and then clean Certain conditions have a very high association with HIV,
them (someone wearing non-sterile gloves) free of blood or whereas others less so; it is the sum total of the clinical
tissue and then sterilize them by heat. picture that is important. Because HIV affects any system,
always take a meticulous general history and make a full
examination.

5.5 Testing & visual recognition Perhaps the most striking features of untreated HIV patients
recognizable before any medical interview is undertaken
Combo kits are now available which detect IgM as well as IgG, are the following (seen obviously mainly in the face):
and so reduce the window period when a common screening (1) Facial rash, typically seborrhoeic dermatitis,
test may show -ve in the presence of early infection (and high (2) Lymphadenopathy,
risk of transmission owing to high viral loads). (3) Herpes Zoster scarring (5-3),
(4) Parotid swelling (5-12),
(5) Unilateral ptosis (5-14),
(6) Weight loss; hair changes & premature ageing.

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Where you see these features, concentrate the remainder of the Some dermatitis may be secondary to other conditions,
medical history and examination for diagnostic purposes on e.g. HIV-related malnutrition leading to pellagra.
further HIV-related conditions. Although, of course, patients Some malignant skin conditions may show a more
with HIV may have non-HIV-related illness, inherently it is aggressive pattern: this has been reported with malignant
more likely that the illness is indeed HIV-related. For example melanoma. Several skin ailments are common with high
a patient with clear signs of immunosuppression complaining HIV association, with Herpes Zoster having a high
of headache is much more likely to have HIV-related causes of predictive value, and Herpes Simplex on the vulva and
headache than a brain tumour. buttocks; eosinophilic folliculitis has only been seen in
HIV+ve patients, particularly where the CD4 count is
Gradation of severity of symptoms and signs is related to <400/μl.
dropping CD4 counts, but this test is not available in most
hospitals, although you can gauge it by the total lymphocyte
count.

5.6 New pathologies & new strategies

In every area, HIV has an impact; not only are new pathologies
seen, but many well recognized problems become more severe.
We provide a brief overview here, but detailed discussion is in
the main body of the text. Of note is that prior to treatment,
there may be several diseases present simultaneously with
HIV. Consequently one symptom may be caused by different
pathologies, and further, different symptoms may have separate
pathologies. So in HIV disease, Occam’s famous razor,
“Numquam ponenda est pluralitas sine necessitate” (‘Plurality
must never be posited without necessity’) is inevitably blunted.

A..SKIN DISEASES (34.4)

In the skin, HIV directly attacks antigen-presenting dermal
dendritic cells and Langerhans cells, which take up antigens,
process them and present them to unexposed T-lymphocytes in Fig. 5-3 HERPES ZOSTER. Blisters, classically ending in the midline
lymph nodes, after which they themselves migrate to the skin
to exert a protective immune effect. Impairment of this system Increased photosensitivity to sunlight and therapeutic
leads to microbial invasion and malignant change. irradiation is common.
Furthermore, contact between HIV-traumatized dendritic cells Typical manifestations of skin disease (34.4) are:
and T cells during antigen presentation causes a surge in HIV Aggressive psoriasis (5-7),
replication. Bacillary Angiomatosis,
Candidiasis,
A fine facial rash is virtually diagnostic; new skin affectations Condylomata (5-13),
in HIV disease are very common, found in >50% of HIV Cryptococcus ulcers,
patients presenting in hospital, and almost in 100% in the Eosinophilic folliculitis,
terminal stages of the disease. Idiopathic maculopapular Florid tinea corporis,
eruptions are frequent and pruritic; these papular dermatoses Herpes zoster (5-3),
must be distinguished from urticaria and lesions due to insect Kaposi sarcoma. (5-4,11),
bites which occur on exposed skin. (Some of these may Molluscum contagiosum (5-4),
respond to dapsone; they do not respond to steroids). Multiple herpes simplex,
Itching is often severe and needs a sedative or antihistamine. Pyoderma gangrenosum,
Seborrhoeic dermatitis (5-6),
Opportunistic infections, such as tinea, candidiasis, Stevens-Johnson syndrome (5-5).
and scabies, especially crusted and Norwegian types, may be It is probable that some of these skin infections destroy skin
florid and widespread. grafts, especially Herpes Zoster and Molluscum
contagiosum.
Bacterial skin infections, especially with Staphylococcus
aureus are more common. Likewise allergic skin reactions are Pressure sores are, alas, all too common in the debilitated
more common, and may be florid and life-threatening: advanced HIV+ve patient; these are often deep and resistant
frequent culprits are thiacetazone, sulphonamides, to healing: prevent them! Gloves, filled with water and tied,
streptomycin, and pyrazinamide. make excellent soft supports.

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Malignant melanoma in white people is 3 times as common in PSORIASIS

HIV disease.

MOLLUSCUM CONTAGIOSUM

Fig. 5-7 AGGRESSIVE PSORIASIS.

B..SOFT TISSUE DISEASE

Kaposi sarcoma (KS) in its aggressive widespread form is

Fig. 5-4 MOLLUSCUM CONTAGIOSUM, producing multiple typically
punctuate lesions.
now recognized as virtually diagnostic of HIV disease
(34.10).
STEVENS-JOHNSON SYNDROME
CLASSICAL KAPOSI SARCOMA

Fig. 5-5 BULLOUS EPIDERMOLYSIS (Stevens-Johnson syndrome),

is a widespread blistering reaction that looks like a burn wound.

SEBORRHOEIC DERMATOSIS

Fig. 5-8 CLASSICAL KAPOSI SARCOMA, typically on the leg,

Fig. 5-6 SEBORRHOEIC DERMATOSIS, which usually affects scalp, producing violet nodules and cutaneous ulceration.
groins, and perineum, but can be widespread.

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Cellulitis (6.22), arising without history of diabetes mellitus or There is chronic staphylococcal carriage with decreasing
trauma, is a common manifestation of HIV; the causative immune competence, and therefore colonization of foreign
organisms remain streptococcus and staphylococcus and the bodies such as catheters is high. The incidence of post-
disease responds to intravenous penicillin or cloxacillin, rest operative wound infections increases dramatically in
and elevation of the affected limb. There is, however, frequent HIV+ve patients, especially if the CD4 count is <200/μl.
skin necrosis requiring debridement and subsequent skin-
grafting. This may occur with pseudomonas aeruginosa Abscess formation, especially de novo, in normally clean
infection where the result is known as ecthyma gangrenosum. anatomical sites should give rise to suspicion of HIV
Facial cellulitis is potentially life-threatening owing to possible disease; in this category are breast abscesses in
spread of organisms to the brain through the cavernous sinus, non-lactating women (6.13), muscle (pyomysositis) (7.1),
and requires aggressive intravenous antibiotic therapy. thyroid (6.12), abdominal wall, penile (6.21) and
retroperitoneal abscesses (6.15). Submandibular and neck
NECROTIZING FASCIITIS abscesses (6.11) are often related to pre-existing
lymphadenopathy and may be tuberculous.
Pressure sores often arise from the combination of inertia,
cachexia and neuropathy in HIV disease.

Leiomyosarcomas in children are unusual lesions noted to

be associated with HIV and specifically to exposure to
Epstein-Barr virus. The lesions occur subcutaneously,
in the respiratory and gastro-intestinal tract, and even in the
kidney. They appear not to be common in Africa to date.

Muscle atrophy is frequent in debilitation; specific wasting

syndromes are also seen with rises in CPK levels and
increased numbers of macrophages in muscle biopsy
specimens.

Lipodystrohy is a generally abnormal degeneration of fatty

tissue, seen in advanced HIV disease, where fat is lost in
Fig. 5-9 NECROTIZING FASCIITIS, which is classically on the scrotum, the extremities, buttocks and face (especially in men) and is
but can appear in the perineum, abdominal wall, neck, limbs or indeed laid down in the neck, abdomen, back and breasts,
anywhere. (especially in women). This is not so well-recognized in
poor-resource settings where malnutrition and HIV-related
Necrotizing fasciitis (5-9, 6.23), describes soft tissue infection Slim disease are so common, and the condition appears to
initially remaining hidden until the blood supply to the skin is be related to the length of time on antiretroviral therapy.
affected by increasing oedema and inflammation; thereupon There is an associated tendency to type 2 diabetes mellitus.
there is rapidly advancing necrosis, if there is excessive No specific therapy has yet been identified.
collagenase production by haemolytic streptococci or
staphylococci and peptostreptococci. The scrotum (Fournier’s Other rare malignancies found are embryonal tumours,
gangrene) and abdominal wall (Meleney’s gangrene) are and Merkell cell carcinoma.
common sites, but you may also see necrotizing fasciitis
associated with HIV in the limbs and neck. This may occur in
infants as well as adults. C..LYMPHADENOPATHY (17.1)
Pyoderma gangrenosum represents a very painful necrotizing Persistent generalized lymphadenopathy has long been
non-infectious ulceration, especially in a non-healing wound, recognized as one cardinal feature of HIV disease and
often associated with fever. This responds to a short course of represents significant immunosuppression as related by
prednisolone 60mg/day (if the CD4 count is >50/μl), depressed CD4 counts; the presence of epitrochlear
application of zinc oxide cream and maybe dapsone. lymphadenopathy is virtually diagnostic of HIV affliction.
Debridement makes it worse!
Typically lymph node enlargement is symmetrical, with
Recurrent infections and abscesses (6.2), multiple and small rubbery nodes palpable; these show follicular
frequently recurring in skin, and soft tissue are also typical in hyperplasia. Cystic degeneration often occurs, especially in
HIV disease; standard methods of treatment are effective, the parotid and submandibular regions. Where nodes are
but attention to every focus of sepsis is essential. Pus swab larger, non-symmetrical, matted and firm, other pathology
microscopy is useful, though the causative organism is most is usually found, principally tuberculosis, Kaposi sarcoma,
often staphylococcal, it may not be so and is sometimes or lymphoma. These are usually large B cell anaplastic,
Gram-ve. Discourage the use of antiperspirant ‘roll-ons’ Burkitt, or aggressive Hodgkin (Grade II) types.
because these may clog up skin pores causing abscesses.

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Histoplasmosis in Latin America, leishmaniasis in South Oropharyngeal carcinoma is 3 times as common with
America and infection with penicillium marneffei in the HIV disease.
Southeast Asia are increasingly common associations of
lymphadenopathy and hepatosplenomegaly with HIV. Kaposi sarcoma (31.8) lesions on the palate or gums
In children with HIV, BCG immunization produces a (5-11) are manifestations of systemic gastro-intestinal
lymphadenitis. involvement. Non-Hodgkin Lymphoma is also frequently
seen.
D..ORAL DISEASE
KAPOSI SARCOMA ON THE GUMS
Oral candidiasis (5-10) is a very well-known manifestation of
HIV disease, which may present in erythematous,
pseudomembranous, hyperplastic forms or angular stomatitis.

ORAL CANDIDIASIS

Fig. 5-11 HIV-RELATED KAPOSI SARCOMA, typically on the

gums or palate: (remember always to look inside the mouth!)

E..NASAL DISEASE

Recurrent rhinitis and sinusitis are the consequences of

mucociliary dysfunction in the nose and sinuses, with
increased atopy, often complicated by bacterial or fungal
infection (the latter if CD4 counts are <50/μl).
Nasal tumours are usually lymphomas or Kaposi Sarcoma.

F..EAR DISEASE

Hearing loss of both sensineural and conductive types can

occur. There may be direct central neurological damage,
effects of HIV directly on the VIIIth cranial nerve, but the
causes below are more common. However, do not forget
Fig. 5-10 AGGRESSIVE ORAL CANDIDIASIS, often extending into the that anti-TB drugs and ARVs may be directly ototoxic.
pharynx and oesophagus.
Acute otitis media, especially with effusion, owing to
White warty projections (hairy leucoplakia) occurring
obstruction of the Eustachian tube by lymphadenopathy,
particularly on the lateral aspects of the tongue and cheeks are
is frequent and often recurrent, and may result in rupture of
diagnostic of HIV disease.
the eardrum. Almost all HIV+ve children have had at least
5 episodes by the age of 5yrs, the frequency being related to
Periodontal disease is common: linear gingival erythema
the drop in CD4 count.
worsens to necrotizing ulcerative gingivitis and periodontitis.
Advanced necrosis may lead to external ulceration on the
Otosyphilis leading to sensineural hearing loss occurs often
cheek, or even to cancrum oris (31.5). In these cases the
suddenly with rapid progression in one or both ears:
demarcation of necrosis is usually clear.
it appears that HIV disease may activate or accelerate pre-
existing syphilis.
Herpetic ulceration of keratinizing epithelium is common.
Otalgia and facial palsy (Ramsay Hunt syndrome) is
Recurrent aphthous ulcers are more severe and long-lasting.
caused by Herpes zoster affecting the geniculate ganglion;
Some may be due to histoplasmosis.
the herpetic rash appears in the ear, and the facial palsy
never recovers.
Tonsillitis is common and severe, often with ulceration, either
in combination with generalized lymphadenopathy or alone.
Otitis externa is often florid with necrosis, and may be
Development into a tonsillar abscess is not uncommon (6.7).
accompanied by invasive fungal infection.

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G..SALIVARY GLAND ENLARGEMENT (17.5) A small lesion with an irregular surface 2-5mm in diameter
appears on the medial side of the limbus usually, spreading
Parotid enlargement is a typical early sign of HIV disease; onto cornea and underlying sclera. Recurrence after
its cause is varied, including lymphadenopathy (as part of excision is fairly common. Where tumour extends into the
generalized lymphadenopathy), salivary and extraparotid sclera, resulting in necrotizing scleritis, the eye is lost.
lympho-epithelial cyst formation, and lymphocytic infiltration
(due to direct infiltration by CD8 lymphocytes). Kaposi sarcoma appears as a slightly raised pigmented
This may represent a beneficial response to HIV infection, and lesion found on the eyelid, conjunctiva or inside the orbit.
patients with salivary gland enlargement seem to experience This may be isolated or multifocal; recurrence after
slower progression of the disease. Frequently, unilateral parotid treatment is usual.
swelling is followed some time later by swelling of the
contralateral side. Molluscum contagiosum consist of raised umbilicated
lesions; when they affect the eyelids, they may become
PAROTID SWELLING large and numerous; an associated follicular conjunctivitis
may occur due to viral shedding.

Cytomegalovirus (CMV) retinitis is the most common

cause of impaired vision in HIV patients: in 30% it is
bilateral; early signs are narrowing of the retinal vessels,
resulting in perivascular exudation and haemorrhage prior
to retinal infarction. CMV is common in those patients who
have had TB; it does not appear to occur if Herpes Zoster
was contracted earlier. Toxoplasma is a rarer cause of
chorioretinitis.

Keratoconjunctivitis sicca (extreme dryness of the

conjunctiva), reminiscent of the Sjøgren syndrome, occurs
in HIV patients, and in particular in association with the
Stevens-Johnson syndrome, and toxic epidermal necrolysis.

Diffuse lymphocytosis syndrome occurs as a malignant

condition where there is perivasculitis of retinal vessels and
lacrimal gland involvement.
Fig. 5-12 PAROTID SWELLING, often bilateral, of cystic soft texture. I..CARDIOPULMONARY DISEASE
N.B. Nasogastric tube only in situ to help nutrition because of
orophayngeal and oesophageal candidiasis.
Cardiomyopathy occurs, often with sudden dramatic
H..EYE DISEASE cardiac collapse: its aetiology is multifactorial.

Keratitis is a severe, rapidly deteriorating infection involving Spontaneous pneumothorax (36.1) occurs especially in
the cornea caused by either: bacteria, fungi, microsporidia, pneumocystis carinii pneumonia, which accounts for up to
Herpes simplex, or Herpes zoster. The cornea is affected in the 60% of pulmonary infection in HIV disease.
latter through the nasociliary branch of the ophthalmic division This occurs frequently in conjunction with
of the Vth cranial (trigeminal) nerve. Progress occurs to cytomegalovirus. Other infections in the lung are mainly
multiple small dendritic and then geographic ulceration and with bacterial pathogens and mycobacterium: in low-and
frequently to perforation. Healing by scarring may give rise to middle-income countries, tuberculosis is extremely
iris adhesions leading to glaucoma, and inevitably corneal common as a manifestation of HIV disease. Pleural
opacification. Once perforation occurs, however, or if a effusion is a common consequence, and empyema thoracis
staphyloma develops, the eye is lost. (9.1) likewise.
However, not all effusions are due to tuberculosis: they
Bacterial conjunctivitis comes as acute or subacute infection, may be secondary to lymphoma, Kaposi sarcoma, or
either staphylococcal or gonococcal. serious bacterial infection.
Open thoracic surgery is fraught with serious pulmonary
Conjunctival carcinoma (28.15) was soon found as a more complications and is ill-advised.
frequent pathology in Uganda, being first described in
Guadeloupe as probably related to HIV, having been noted as Tuberculous pericarditis and pericardial effusions (9.2)
an oddity much earlier. (This pattern mimics the story of are common.
Kaposi Sarcoma). There appears to be an increased
susceptibility to ultraviolet light in the presence of human
papilloma virus-16 infection.

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J..OESOPHAGO-GASTRIC DISEASE Other HIV-related conditions may give rise to severe

abdominal pain:
Oesophageal candidiasis. Oral candidiasis (5-10, 30.4) is a HIV-pancreatitis (15.11,
very frequent manifestation of immune deficiency. Infestation Severe HIV-cystitis,
with candida may spread further into the pharynx and Retroperitoneal abscess (6.15),
oesophagus, where if very copious will give rise to symptoms Necrotizing fasciitis of the abdominal wall (6.23),
of dysphagia. It may be absent in the mouth though present in Abdominal wall abscess,
the oesophagus! Complete oesophageal obstruction can occur. Intestinal wall haemorrhage from Kaposi sarcoma
(mimicking colitis).
Diffuse oesophagitis may be due to herpes simplex, and result
in ulceration; discrete ulceration is more likely due to There may be a complex mass of adhesions with all of the
cytomegalovirus. There may be profuse haemorrhage. above, including bowel perforation. Of course tuberculosis
Some of these ulcers are, however, idiopathic. They often may affect any abdominal organ, including the pancreas,
result in strictures. liver and spleen. The classic ‘doughy’ abdomen occurs in
c. 50% of cases.
Tuberculosis may affect the oesophagus without being present
elsewhere; a broncho-oesophageal fistula may result; the An ascitic tap will only demonstrate AAFB’s in 25% of
oesophagus is too friable to attempt stenting in this cases, but a raised adenosine deaminase level helps to
circumstance. confirm the diagnosis. However in areas of high
endemicity, a high lymphocyte count in the ascitic fluid
K..THE ACUTE ABDOMEN would be sufficient to justify TB treatment.

(1) PERITONITIS (10.1) (2) INTESTINAL OBSTRUCTION (12.2)

You will see the causes of peritonitis as in HIV-ve patients; Causes of intestinal obstruction may again be non-HIV
HIV-positivity does not of course necessarily imply an HIV- related, but specific HIV causes are:
related pathology as the cause. Indeed some common causes Tuberculous adhesions/mass/intestinal stricture,
of peritonitis, such as gynaecological pelvic inflammatory Lymphoma of small bowel,
disease (PID), are more common and more severe in HIV+ve Kaposi Sarcoma of small and large bowel,
patients. Likewise pelvic abscesses (from any cause, but Mesenteric Lymphadenopathy,
especially PID) are more common and more extensive. Intussusception (12.7).

Nonetheless you may see HIV-related pathologies frequently; Tuberculous adhesions are often thick and unyielding (and
these include: may be detected as septa on ultrasonography in an ascites-
Primary peritonitis: most common, filled abdomen). A tuberculous mass usually occurs in the
Spontaneous bowel perforation, especially in the distal right iliac fossa but any site may be affected; an intestinal
ileum (usually due to CMV) or colon, stricture occurs in the ileum in 70%, in the jejunum in 15%,
Tuberculous peritonitis (16.1) in the following forms: and in both in 15%.
Multiple peritoneal seedlings with ascites,
Tuberculous mesenteric lymphadenopathy In a few cases, the signs of intestinal obstruction may
(with or without ulceration), mimic a paralytic ileus thought to be related to an HIV-
Ileocaecal tuberculous mass (Tuberculoma), neuropathy.
Tuberculous colitis (mimicking ulcerative colitis),
Tuberculosis of Fallopian tubes and ovary, L..ABDOMINAL MASS
Abdominal wall sinus.
Cryptococcal peritonitis, multiple superficial small white Lymphoma or tuberculoma is likely to be the diagnosis in
nodules seen on the omentum and serosal surfaces, a younger patient; tuberculous abscess of the liver or spleen
Mesenteric thrombosis (12.14), usually a venous infarction, are not rare, but common local conditions should still head
Colitis (in adults), from enteropathic E. coli or CMV, the diagnostic list in HIV+ve patients, especially where,
mimicking amoebic colitis, as in schistosomiasis, HIV appears to have little impact on
Necrotizing enterocolitis (in adults and infants beyond the the disease pattern.
neonatal period;10.4),
Acalculous cholecystitis (caused by cryptosporidium, CMV, Do not assume a right iliac fossa mass to be a walled-off
microsporidia, lymphoma or KS). acute appendix! Whilst the diagnosis of an abdominal mass
follows standard principles, keep HIV-related conditions in
In late stages, the gallbladder may perforate, mind.
but perforations may be multiple and small with inflammatory
exudation.

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M..HEPATO-BILIARY DISEASE O..OBSTETRIC PROBLEMS

Liver abscess (15.10), especially tuberculous, is not Pregnancy worsens the HIV condition if in the late stages;
uncommon. wasting contributes to maternal and perinatal mortality;
puerperal sepsis (22.14) is more common and more severe.
Hepatitis is common: either with hepatitis B or herpes virus, Although Caesarean section reduces the transmission of
cryptococcus, or induced by drugs. Granulomatous hepatitis HIV to child, it is not practical to advocate such a general
occurs with fungal infections or mycobacteria. policy. Introduce practices to reduce transmission (5.3).
Unusual infections, e.g. peritonitis after postpartum tubal
Hepatoma is 7 times as common with HIV disease, but the ligation, or pubic osteomyelitis after spontaneous labour,
effects of Hepatitis virus exposure are probably more are seen.
important.
Puerperal psychosis may be difficult to differentiate from
Acalculous cholecystitis has been discussed previously under HIV-cerebral encephalopathy.
‘Acute abdomen’. Good contraception (and that usually does not mean the
contraceptive pill), is needed in HIV+ve women.
Cholestatic jaundice (15.7) may arise from several types of The contraceptive pill is a bad option because ARV therapy
HIV-related pathology: and antibiotics (especially rifampicin) interfere with their
papillary stenosis, absorption and so they become far less effective (unless
sclerosing cholangitis, 2 pills a day are taken). Fever, vomiting diarrhoea and the
lymphadenopathy in the porta hepatis, especially TB. AIDS dementia syndrome also interfere with effective use.
Cryptosporidium and cytomegalovirus have been implicated; The dangers of IUD’s are overstated, but Depo-Provera is
this is not necessarily a late complication of HIV disease. probably the drug of choice.

A pancreatic mass may be tuberculous, lymphoma or P..UROLOGICAL DISEASE

adenocarcinoma, behaving more aggressively, often associated
with portal vein thrombosis. Neuropathic bladder is a common problem in HIV
disease; it may present with irritative symptoms of urgency
N..GYNAECOLOGICAL DISEASE and frequency, which respond to anticholinergic therapy
e.g. imipramine. Less commonly there are obstructive
Pelvic inflammatory disease, pelvic lymphadenitis and symptoms leading to urinary retention. Where the
pelvic sepsis (23.1), especially post-abortal (23.2), neurogenic bladder is due to Guillain-Barré syndrome or
are more common and more virulent in HIV-disease. transverse myelitis, expect spontaneous recovery.
They are promoted by the use of intra-uterine contraceptive Otherwise a trans-urethral incision of the prostate provides
devices; recurrent abortions, primary subfertility due to HIV a remedy in men, and intermittent self-catheterization in
disease and permanent infertility due to previous infection are women.
very frequent consequences. Recurrent sexually-transmitted
infections are very common. Urethral stricture (27.9) may also cause acute urinary
retention; the stricture is usually more severe than in
Tuberculous infection of tubes and ovaries is common. non-HIV patients. This commonly presents in HIV+ve
Dense matted adhesions are frequently found with perforation patients through its complications, namely periurethral
into bladder, small, large bowel or rectum. Low rectovaginal abscess and fistula formation. The development of
fistulae, unrelated to obstetric trauma are seen in sexually ‘watering can’ scrotum and perineum is frequent.
active women and children <5 years. Do not perform an open urethroplasty because it has a high
complication rate.
Cervical carcinoma is 10 times more frequent, affects
younger females, and is more aggressive; recurrence is Fournier’s gangrene (6.21,23) is a very high risk in HIV
common. patients following urethral injury. It may often, however,
occur de novo.
Herpetic vulvovaginitis, often ulcerative, is common and huge
extensive vulval condylomata very often seen. Their presence Prostatic abscess (6.19), tuberculous and non-specific
in young girls does not necessarily imply sexual abuse; prostatitis are specific HIV-related problems, frequently
long-standing condylomata may however develop into resulting in urinary retention. Tuberculous prostatitis
carcinoma. mimics prostatic carcinoma completely, even to the extent
of giving rise to raised prostate specific antigen (PSA)
Ovarian lymphomas of Burkitt-type are seen. serum levels.

Nonspecific chronic pelvic pain has been a difficult but

regularly seen problem in HIV patients.

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Focal segmental glomerulonecrosis is the commonest cause Do not underestimate the possible complications of elective
of HIV-related renal impairment; renal tuberculosis remains circumcision, especially if you use a LA ring block:
rare but consider it in chronic sterile pyuria. necrotizing fasciitis, abscess and also the risk of
Although common in the HIV population, epididymitis shows haemorrhage, particularly where thrombocytopenia is
no real differences in presentation and treatment with the present, are serious problems. Though these complications
non-HIV population. are quite common with HIV+ve patients, they can also
occur to others.
Tuberculous epididymitis is however more common; Recommendations for circumcision to prevent HIV
the lesion is typically firm. transmission fall in the same category as the use of
condoms: although it may help, it does not get to the root of
HIV-related cystitis may be aggressive and extremely the problem. You must carefully counsel your patient that
debilitating. The predominant symptoms are painful circumcision does not protect him from HIV infection,
urinary frequency, suprapubic pain and haematuria but may just lowers the risk.
(micro- or macro-scopic) without any demonstrable urinary
tract infection. Cystoscopy reveals a highly characteristic Condylomata may be very profuse on the foreskin and
uniformly congested appearance with no ulceration and no may encroach onto the glans penis and into the urethral
significant reduction in bladder capacity. The histological meatus.
appearance is like a non-specific interstitial cystitis without
mast cells, with no cytomegalovirus found. Erectile dysfunction is very common in HIV disease,
and seems to have a multifactorial origin; treatment with
Urinary tract infections occur in c.15-20% of males with sildenafil and related drugs pose huge moral and ethical
advanced HIV disease (CD4 <200/μl), most commonly with issues.
pseudomonas aeruginosa.
All types of sexually transmitted infections are inevitably Q..ANORECTAL DISEASE (26.2)
common in HIV+ve patients, and therefore a combination of
diseases is frequent. You will find a variety of anorectal lesions in HIV+ve
patients, and their severity relates closely to CD4 levels;
Balanitis co-existing with chancroid, condylomata or with in all patients they are common, although they are
malignancy. This may be in the form of squamous carcinoma particularly numerous (c. 30%) in homosexuals, where they
or Kaposi sarcoma. There may be a continuum of histological have a somewhat different pattern. As many practitioners
change from condyloma to squamous carcinoma, suggesting a have a natural reluctance to examining the anal region, they
synergistic interaction between the papilloma virus and HIV. are often referred to as ‘piles’; however haemorrhoids are
Malignancy of the foreskin however remains rare; frankly per se not part of the spectrum of HIV anal pathology.
necrotic ulcerative penile lesions are usually due to chancroid. Many of the lesions are resistant to treatment, and their
Patients may request circumcision (27.29) hoping thereby to aetiology is not known; however, this does not mean that
avoid recurrent penile ulceration; this may then of course occur you can do nothing for patients with these conditions.
on the glans penis itself. The operation of circumcision is not However, do not undertake elective anorectal surgery
without risk: severe necrotizing fasciitis of the penis can occur lightly: many authors have reported poor or absent wound
post-operatively. There appears, at least in certain cases, to be healing often after many months. Distal septic
a microangiopathy associated with balanitis; this may be the complications such as meningitis may also occur.
predisposing factor in the development of necrotizing fasciitis
and it may be exacerbated by increased tension when LA is Idiopathic anorectal ulcer appears first as a mucosal
used in a penile block. You should therefore perform the laceration within the anal canal, and gives rise to symptoms
operation only under GA or using a caudal block. identical to the classical anal fissure, i.e. pain and bleeding
per rectum. However, you will see no anal skin lesion on
Penile abscess (6.21) de novo is diagnostic of HIV infection. gentle parting of the buttocks, because the lesion is internal,
The infection usually spreads from the penis to the scrotum, usually just proximal to the dentate line. Furthermore there
rather than the reverse as in the classical Fournier’s gangrene. is rarely anal sphincter spasm, and often diarrhoea rather
In the absence of urethral stricture or diabetes mellitus, than constipation. Pain is persistent, usually associated with
necrotizing fasciitis of the penoscrotal tissues is likewise some intermittent bleeding per rectum, particularly after
diagnostic of HIV disease. defecation.
Don’t necessarily refuse a request for circumcision in HIV+ve The mucosal defect then deepens and becomes palpable as
patients on traditional or social grounds; there may be a an ulcer with smooth benign-feeling edges. As this ulcer
protective role in HIV transmission in the act of circumcision. deepens further, it may penetrate into the vagina or urethra
The epithelium of the exposed glans penis in the circumcised or appear as a large fistula externally.
male changes from columnar to stratified squamous, and may No single agent has been implicated in this lesion, although
thus be more resistant to ulceration. in some cases cytomegalovirus, chlamydia trachomatis
However, the morbidity and, in some cases, mortality of (26.11), and herpes simplex virus have been found.
circumcision, especially where medical resources are scarce, There is commonly associated infection, with patients
may make this procedure dangerous. reporting pus draining per rectum.

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Superficial breakdown of perianal skin with excoriation Squamous carcinoma (26.7) may be heralded by the
is often associated with chronic diarrhoea; neoplastic change seen in anal intra-epithelial neoplasia
control of loose stools is therefore obviously important. (AIN), or be the result of chronic infestation by
Vesicular excoriation is due to herpes simplex. condylomata, especially if florid, or arise de novo.
Careful examination to exclude fistulae and abscesses is vital. The incidence of HIV-related anal carcinoma is rising and it
is 60 times more common than without HIV disease, but
Fistulae (26.3) in HIV+ve patients are often complex and this may be mostly due to the risks of ano-receptive sexual
multiple. They are frequently high or intersphincteric intercourse.
(intermediate) and are therefore not amenable to simple laying (Lymphoma and Kaposi sarcoma may also be found at
open. In fact, even for low superficial fistulae, the laying open the anus.)
may result in non-healing perianal wounds, especially if CD4
counts are <200/μl. Proctitis: Just as in colitis, the rectum may be affected by a
Many fistulae arise from sepsis, but some as a result of severe inflammatory process; cytomegalovirus, herpes
extension of the idiopathic anal ulcer described above. simplex, chlamydia or enteropathic E. Coli may be the
In these cases, the fistula is wide and may readily admit the cause.
examining finger. Fistulation can occur to the outside skin,
but also to the vagina or bladder. This occurs both in adults and R..VASCULAR DISEASE
small children. If the fistula was not present at birth, it is
pathognomonic of HIV-disease. Any major artery can be involved; the pathology affects
mainly the adventitia with leucocytoclastic vasculitis of
Anal and perianal warts (26.6) are often very extensive; vasa vasorum and periadventitial vessels, proliferation of
their excision or diathermy ablation surprisingly results in rapid slit-like vascular channels, chronic inflammation and
wound healing, presumably due to an epithelial growth factor fibrosis. There is associated medial fibrosis with loss and
in the papilloma virus. Contact tracing in poor-resource fragmentation of muscle and elastic tissue, and similar
environments is a pipe-dream, and therefore recurrence by fragmentation in the internal elastic lamina of the intima,
reinfection is frequent. Moreover, if not all condylomata are with calcification.
removed, and they can extend far up in the anal canal,
they quickly re-establish themselves. Beware when using Arterial occlusion (35.2) or aneurysm formation (35.8)
diathermy on these lesions: HIV may be transmitted by the are the end result; the former is much more common,
smoke, so always wear a mask and aspirate away the fumes. but increasing numbers of aneurysms are seen in HIV+ve
patients.
PERIANAL CONDYLOMATA Arterial occlusion in limbs results obviously in gangrene;
in poor-resource countries, patients rarely present with
claudication, and the deterioration of symptoms is usually
too rapid to allow early presentation. Thus arterial
reconstruction is hardly ever an option; you should also
have serious qualms about using prosthetic material in
HIV+ve patients as the vessels take sutures poorly,
and secondary infection of the graft is a very definite risk,
often with fatal outcome. Results of surgery for
atheromatous disease (i.e. not HIV-related) in HIV+ve
individuals may however be more successful.
Thrombosis may also occur in mesenteric vessels, or
cerebral arteries resulting in a cerebro-vascular accident.
Aneurysms tend to occur in the carotid and superficial
femoral arteries, although any artery may be involved and
multiple lesions are seen. Spontaneous arteriovenous
fistulae also result.

Deep vein thrombosis occurs with 10 times greater

frequency, though you will detect less than 1% of cases
clinically. Risks of surgery are obviously further increased
when you take this statistic into consideration, especially as
you can use prophylactic anticoagulants only with
reluctance in the presence of thrombocytopenia.
Fig. 5-13 CONDYLOMATA (warts), often extensive with underlying
neoplastic change.

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S..ORTHOPAEDIC PROBLEMS UNILATERAL PTOSIS

There is increased risk of infection especially when implants

are used; you may see late infection long after implants have
been inserted, where surgery has often been done before
seroconversion.
The larger the implant, the bigger the problem: bone infections
then often fail to respond to antibiotics, removal of the implant,
debridement and subsequent sequestrectomy.
Never put implants in open fractures in HIV patients!

Thus non-operative methods are usually more suitable,

especially when they are obvious signs of immunosuppression
(CD4 levels <200/μl); external fixators are preferable if
practical. Remove implants as soon as possible, once their
effectiveness is over. Explain fully the merits and demerits of
internal fixation before you carry out any such operation.

Adult bone infection (osteomyelitis) (7.3) occurs usually in

the lower femur or upper tibia, often bilaterally; staphylococci Fig. 5-14 UNILATERAL PTOSIS, usually without pupillary changes.
are usually found, but salmonellae and gut organisms are often
seen. Despite appropriate treatments, infections frequently do Neuropathies and myelopathies are common, resulting in
not resolve and amputation may be necessary. facial palsy (especially at seroconversion), ptosis (5-14),
impotence, paraparesis, urinary retention or incontinence.
Septic arthritis (7.17) occurs more frequently in HIV-disease,
especially if joint replacements have been inserted. Knee, hip, Opportunistic cerebral infections with toxoplasmosis,
shoulder, ankle, elbow and wrist are commonly affected by the cytomegalovirus, herpes simplex, and blastomycosis are
same organisms as osteomyelitis. common.

Tuberculous arthritis affects HIV-patients similarly to Cryptococcus meningitis is a typical manifestation of

non-HIV: primarily the spine (32.4), and then the hip and knee advanced HIV-disease; tuberculous meningitis is more
are involved. Relapse is not uncommon after treatment; common in HIV-patients and often results in secondary
except where immune competence is reasonable (CD4>200/μl) hydrocephalus involving the basal cisterns.
avoid surgery to decompress the vertebral column to relieve
paraplegia or arthrodese painful destroyed joints. Herpes zoster may affect the motor roots in HIV-disease:
a claw hand may result.
Reactive HIV-arthritis causes painful swelling and joint
effusion, especially of knees and ankles, and may be acute U..HAEMATOLOGICAL DISEASE
(mimicking septic arthritis) or more insidious, usually bilateral
and sometimes migratory; recurrence frequently occurs in the Pyrexia without obvious cause is frequent.
same joint which had been quiescent for months.
The arthritis may arise as a result of reaction of diarrhoea Chronic anaemia is common with bone marrow
bacterial fragments carried in the circulation: aspiration yields suppression of single or multiple cell lines. Infiltration of
opalescent fluid filled with leucocytes. Chronic debility results bone marrow with leishmaniasis or toxoplasmosis is seen.
with permanent joint stiffness where relapse occurs (often with There is a drop in levels of interleukin 4 & 5, needed in
resolution of physical signs) haemopoiesis.
Where rheumatoid arthritis, Reiter’s disease or ankylosing
spondylitis occur with HIV disease, their response to There is an increased risk of bleeding in HIV disease;
anti-inflammatory drug treatment is usually poor. when thrombocytopenia is overt this may be
catastrophically serious. Platelet numbers may be
Inflammatory conditions of tendons and ligaments, satisfactory, but their function not so.
e.g. tennis elbow, Achilles tendinitis, plantar fasciitis are
common, and usually recur after treatment. Idiopathic thrombocytopenia responds to splenectomy,
but in HIV-patients the risks of pneumococcal and other
T..NEUROLOGICAL DISEASE sepsis, including malaria, outweigh the advantages.

Transverse myelitis, leucoencephalopathy, progressive All these complications may be correlated to CD4 cell
dementia, and encephalitis, occur through the strong affinity counts and can therefore give an indication of the stage of
of HIV for neuronal cells. advancement of the disease, and also of its regression with
treatment:

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CD4 Infectious complication Non-infectious Leucopenia is common with especially a lymphopenia;

count Complication a leucocytic response to infection is often not present.
However, leukaemia can develop after ARV treatment is
>500/ Acute HIV syndrome Persistent generalized started.
μl Lymphadenopathy
Skin rashes Immunoglobulins, especially IgE, are raised, and so plasma
Salivary gland swelling viscosity goes up, with rise in ESR. Total globulin levels
Guillain-Barré disease rise, with drop in albumin/globulin ratio.
Myopathy
Aseptic meningitis
Colitis 5.7 HIV & tuberculosis
200- Pneumonias Carcinoma Cervix
500/μl Pulmonary TB B-cell lymphoma Tuberculosis (TB) can affect any organ in the body, and so
Herpes zoster Anaemia is found in surgical patients either as coincident pulmonary
Kaposi sarcoma Mononeuritis multiplex disease, or as primary cause of their complaint (e.g. TB
Oral candidiasis Lymphocytic lymphadenitis (17.4), TB arthritis (32.3), abdominal TB
Recurrent skin infections interstitial (16.1), gluteal sinuses, epididymal TB (27.23) etc.)
Primary peritonitis pneumonitis The advent of HIV disease has severely increased its
Oral hairy leucoplakia incidence throughout the world, and in many countries TB
Idiopathic thrombo- is a strong indicator of HIV disease.
cytopaenia You may see bovine TB where immunization of cattle and
Gingival erythema pasteurization of milk is not routine.
Seronegative arthritis
Vasculitis Extra-pulmonary TB is an even stronger indicator of HIV.
<200/ Pneumocystitis carinii Wasting Therefore test for HIV in every TB patient. Dissemination
μl Pneumonia Peripheral neuropathy is more common as the CD4 counts fall <200/μl.
Extra-pulmonary/ Non-Hodgkin’s There may be TB outside the lung without it being inside
Miliary TB lymphoma the lung!
Necrotizing fasciitis Cardiomyopathy
Cellulitis Encephalopathy The clinical diagnosis of TB can be difficult; especially in
Chronic mucocutaneous Myelopathy/ lymph nodes, but also in pus and other solid organs,
herpes simplex Radiculopathy aspiration for acid-alcohol fast bacilli (AAFB) by direct
Oesophageal candidiasis Dementia smear microscopy or using Ziehl-Neelsen (ZN) staining is
Anal ulcer/ useful, especially if histology is not available. Use simpler
Perianal excoriation cold staining methods: flood the smear with concentrated
carbol fuchsin for 10mins without heating, and wash with
<100/ Disseminated herpes Lipodystrophy water; then flood the smear with Gabbet’s methylene blue
μl simplex for 2mins and again wash with water. Dry the smears as for
Toxoplasmosis/ ZN staining. Recent methods (Gene Xpert) detecting DNA
Blastomycosis sequences by using a polymerase chain reaction (PCR)
Cryptococcal meningitis through nucleic acid amplification tests are very sensitive
Chronic cryptosporidiosis even in HIV+ve patients and can detect rifampicin
Chronic isosporiasis resistance; if the equipment is available, the cartridges are
Oesophageal candidiasis now inexpensive, easy to use and recommended by WHO.
Respiratory candidiasis
Salmonella (non-typhi) Gabbet’s methylene blue: Methylene Blue 1G, Absolute Alcohol 30ml,
Concentrated Sulphuric Acid 20ml + Distilled Water 50ml.
septicaemia
<50/μl Disseminated CNS Lymphoma Naked eye appearances of caseation are virtually
cytomegaloviris Pancreatitis diagnostic, but may be confused with necrotic lymphoma.
Necrotizing gingivitis/ Tuberculin (Mantoux and Heaf) testing is no longer
Cancrum oris reliable, except for children <3yrs who have not had BCG.

CD4 count WHO Stage In areas of high TB endemicity, you may be able to
>500/μl I diagnose TB by a lymphocytosis on pleural fluid,
200-500/μl II - III pericardial fluid or simply the presence of para-aortic
<200/μl IV lymphadenopathy on ultrasound. Pleural fluid usually has
The T-cell profile changes with drop in levels of CD4 cells and fibrinous strands visible on ultrasound.
rise in CD8, with drop in ratio CD4/CD8 <2; there is a total
drop in T-cells late in the disease. However, a T-cell leukaemia
may occur with rise in numbers.

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It is important to screen sputum also for AAFB (‘open PTB’) If the CD4 count is <50/μl, however, start ARV treatment
in every patient for good infection control, especially in the as tolerated, but avoid nevirapine and substitute efavirenz
community. A chest radiograph may not show classical apical which is much more expensive. Otherwise start ARV
disease, but rather lower lobe infection; there is less cavitation treatment after 2wks of anti-TB therapy.
and a miliary pattern is common (especially when the CD4
count is low). It is important to perform radiography when The main drawback with TB drugs is their side-effects,
treatment is finished, and to file films properly for which are often shared by anti-retroviral drugs:
future cross-reference.
Toxicity TB Drug ARV Drug
Do not start treatment without arranging contact tracing, Neuropathy H d4T, ddC, ddI
especially babies and infants, and notification. Hepatitis & R, H, Z, S NNRTI’s
Special charts are available in many countries. Follow your Rash
regional regime, or otherwise, the WHO approved standard, Nausea Z ddI, AZT, PI’s
using a directly observed treatment scheme (DOTS): Visual loss E -
Intensive Phase: 2months Isoniazid (H), Rifampicin (R), Hearing & S -
Pyrazinamide (Z), & Ethambutol (E), followed by Balance loss
Continuation Phase: 4months HR. (N.B.Names of ARV drugs in 5.8)
(Note, however, that visual loss is usually the result of
Extend this continuation phase to 5months for TB epididymitis, CMV retinitis rather than a side-effect of TB drug therapy)
6months for spinal TB with neurological problems, TB
pericarditis and meningitis, and 9months for renal TB. If a patient is already on ARV treatment when you
(An alternative is 6months of Isoniazid and Ethambutol.) diagnose TB, don’t stop the ARV drugs!
Do not use Ethambutol in children <10yrs.
If patients do not complete their treatment courses, or if
If the patient has had treatment before, initial treatment is many different treatment regimens are used, resistant
probably best in hospital: use longer treatment phases: strains are likely to develop. Multi-resistant TB has
Intensive Phase: 2months Streptomycin (S), plus HRZE, surfaced in some parts of the world: 2months of
followed by 1 month HRZE, and then, streptomycin are then recommended but get specialist help;
Continuation Phase: 4months HRE. the possibilities of untreatable TB, if combined with HIV,
Do not use Streptomycin in pregnancy; or (and Ethambutol) to would be disastrous. For these reasons, prophylactic
children <10yrs. Thiacetazone is no longer routinely used. treatment of HIV+ve patients with isoniazid is only
recommended where tuberculosis is not so prevalent: follow
Dosages are weight-dependant: as the patient improves and he national programme guidelines!
gains weight, so you may need to alter the dosage; these are
daily oral doses:
5.8 Treatment
Weight Isoniazid Rifam- Pyrazin- Etham- Strepto-
(H) picin amide butol mycin The virus multiplies at an alarming rate: within a week of
(R) (Z) (E) (S) seroconversion there are 107-8 RNA copies/ml.
5-9kg 50mg 75mg 250mg - - In 6-12 months the viral load reaches an equilibrium where
11- 100mg 150mg 500mg - - it can usually be maintained by medication for several
20kg years.
21- 200mg 300mg 1000mg 800mg 500mg
33kg ARV therapy has proved remarkably successful, though
34- 300mg 450mg 1500mg 800mg 750mg eradication of viral reservoirs has not been possible. You
50kg should maintain long term treatment, though this is still
expensive; however costs have come down dramatically
>50kg 300mg 600mg 2000mg 1200mg 750mg
through WHO campaigns; so use this resumé if you can.
Unfortunately still only c.50% of people with HIV needing
Fixed dose combinations may be available, and help patient treatment worldwide are getting it.
compliance; twice or thrice-weekly regimens are being
introduced to make DOTS easier, but dosages will then differ. A willingness and commitment to long-term therapy is
essential; consider the financial costs, and the potential
Control neuropathy with Isoniazid with Pyridoxine barriers ahead. Treat co-morbidities, and manage
(Vitamin B6) 50mg tid; prophylactic treatment is 20mg od. psychosocial issues: the drugs are not the whole story!
Most of the problems with HIV treatment occur with A combination of drugs is necessary; otherwise early drug
rifampicin which induces liver enzyme breakdown of ARVs resistance is inevitable, and further treatment practically
making them less effective; generally start anti-retrovirals after impossible.
the intensive 2month phase of TB treatment. Rifabutin is an
alternative to Rifampicin.

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Reduction of viral loads by 70-80% is usually possible with at Recommended initial therapy is one NRTI from Category
least 95% adherence to drug regimes, but about 30% of I, one from Category II, and one NNRTI. Use an extra
patients default treatment. NRTI from Category III if the viral load is <55,000
copies/ml: monitoring of viral load and CD4 counts is
Agents can be divided into: important.

Type Abb. Function Name Abb. Normally treatment was only started if the CD4 count was
<200/μl, though evidence now suggests it may be better to
Nucleoside NRTI Mimic stavudine d4T start when the count is <500/μl. Treatment is necessary
Reverse Cat I normal zidovudine AZT regardless for clinical stages III & IV, co-infection with TB
Transcriptase building or Hepatitis B (include TDF and 3TC or FTC), pregnancy
Inhibitors blocks of (avoid AZT if HB <80g/l) or where the partner is HIV-ve.
HIV-DNA
NRTI didanosine ddI Other combinations are 3 NRTI; 2 NRTI + PI; 2 NRTI +
Cat II lamivudine 3TC 2PI; or NNRTI + PI. Do not use two NRTI’s alone; PI’s are
zalcitabine ddC metabolized by cytochrome P450 which is inhibited by
NRTI abacavir ABC ritonavir.
Cat III This enhances their efficacy if used in combination,
Nucleotide NtRTI as NRTIs tenofovir TDF but adds significant side-effects, especially metabolic.
Reverse emtricitabine FTC Combination drugs are available. Both d4T and ddI are
Transcriptase being phased out because of their toxicity.
Inhibitors Follow nationally agreed guidelines, as with TB therapy.
Non- NNRTI Directly delavirine DLV
Nucleoside inhibit efavirenz EFV Screen patients for anaemia, TB, Hepatitis B and syphilis
Reverse early nevirapine NVP and treat these before starting ARV therapy. Try to get
Transcriptase stages of etravirine ETR renal and liver function tests done. Do not forget to do the
Inhibitors replication pregnancy test in women of reproductive age!
Protease PI Directly amprenavir APV
Inhibitors inbibit last indinavir IDV Treatment for children should also follow nationally
stages of nelfinavir NFV agreed guidelines: use first-line therapy with RTV-boosted
replication ritonavir RTV LPV for babies <3yrs and EFV for those >3yrs, together
saquinavir SQV with 2 NRTIs
atazanavir AZV
lopinavir LPV Sudden discontinuation of all therapy usually results in
darunavir DRV viral rebound within a month with ‘wild-type’ HIV strains;
discontinuation of therapy even when no detectable virus is
Dideoxy- Hydroxy- Promotes Hydroxy-
found for 3yrs almost always results in viral rebound in
nucleotide urea NRTI urea
3months.
reductase activity
This means that if you have severe complications after
inhibitor
abdominal surgery resulting in your patient not being able
to take his medication, all the problems described may
The main drawback of these drugs is their side-effects and emerge. Consider carefully therefore before you undertake
interactions with other drugs (especially TB treatment, which complex elective procedures in the abdomen.
often means taking 6 or more drugs), and hence their New types of drugs on the horizon are fusion inhibitors and
tolerability. integrase/CCr-5 inhibitors.
Avoid Efavirenz during pregnancy.
Certain combinations are contra-indicated either because they Recurrence of HIV-related disease if no antiretrovirals are
work as antagonists, or are excessively toxic to peripheral used is virtually inevitable with many complications,
nerves or bone marrow. Other toxic side-effects, potentially but especially so with TB and malignant disease such as
fatal, are: pancreatitis, hypersensitivity reactions (including Kaposi sarcoma or lymphoma.
Stevens-Johnson syndrome) and lactic acidosis (with d4T, ddI Co-infection with hepatitis B hugely increases the
or AZT): this presents with abdominal pain and dyspnoea. mortality.
Long-term side-effects are lipodystrophy, osteodystrophy and
insulin resistance. Treatment to reduce mother-to-child transmission is
now standardized: use zidovudine 200mg at the onset of
Occasionally you will need to substitute one drug for another labour. If pains turn out to be false labour, try a repeat dose
of the same type: get advice about this. of 200mg at the actual onset of labour. Alternatively advise
Nonetheless you should warn patients of potential side-effects, a dose at 28wks’ gestation at home, in case premature
e.g. vivid dreams with starting EFV, rash with NVP, anaemia labour occurs, with instructions as to when to take the drug.
with AZT, peripheral neuropathy with d4T or ddI.

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Further, use one 6mg dose to the new-born baby (in liquid
form) between 48 and 72hrs after delivery, or at discharge.
For babies under 2kg, reduce the dosage to 2mg/kg. If the baby
vomits <1hr after taking the medication, repeat the dose.
Should the baby be born <2hrs after the mother had her dose,
supply an immediate dose to the baby, and repeat this at
discharge.

Post-exposure prophylaxis (PEP): after a sharps injury or

splash onto mucosal surfaces, wash the affected part
immediately in warm water. For a case of rape, obtain
specimens, but do not use a douche. Clean a human bite wound
by copious rinsing. Significant injuries warrant ARV treatment:
a single drug regime of zidovudine 200mg tid for 4wks reduces
the risk of seroconversion by 80%, but adding another category
NRTI drug (e.g. lamivudine 150mg tid) will further reduce
the risk. Severe injury, gang rape, rape with immediate
life-threatening injury, or inadvertent HIV-affected blood
transfusion warrant addition of a PI drug also despite
side-effects.

Obviously HIV testing of the victim and the source is

mandatory; stop treatment if a HIV-ve result is confirmed from
the source (but this may still only signify the ‘window’ period).
An HIV quick test may be -ve even with high viral loads in the
period of early seroconversion. A hospital policy on PEP is
advisable: some may claim a needle injury otherwise to obtain
antiretroviral drugs surreptitiously.

Adjuvant therapy: in Kaposi sarcoma, and HIV-related

lymphoma, chemotherapy will not eliminate malignancy,
so you should give antiretroviral therapy in addition.
If you do not, recurrence is inevitable.

You might also consider antiretroviral treatment when inserting

metal into bone, in order to prevent septic complications,
but this area is still controversial.

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For fluctuation to be a useful sign, a minimum quantity of

6 The surgery of sepsis pus must be present, and it must be near the surface.
Do not wait till a huge bag of pus has formed and much
tissue has been destroyed. Use a needle to aspirate: you
will be surprised how often you find pus! Even if you do
6.1 'Where there is pus let it out' not find pus, an incision will allow infection to drain more
readily (by the path of least resistance).
Draining pus is the commonest surgical operation in low
and middle income countries all over the world. It is also
one of the most useful and usually one of the simplest.
Quite a small district hospital can expect to drain 200 large
abscesses each year, some containing up to 3 litres pus.
Although pus can collect almost anywhere, particularly
important sites are the breast (6.13), muscles (7.1),
bones (7.2), joints (7.16), hand (8.1), pleura (9.1),
peritoneum (10.1), and eye (28.3). The most serious
consequence of pyogenic infection is septic shock.

Why sepsis of all kinds is so common is not altogether

clear, but malnutrition, anaemia, HIV, diabetes and poor
hygiene may all play a part. Over 50% of patients with
surgical sepsis are malnourished (with protein and calorie
deficiency): the malnutrition is either primary or arises
because of the sepsis. It may not be immediately visible in
fat patients! This malnutrition increases the risk of further
infection, pressure sores, pneumonia and multi-organ
failure.

Abscesses are more common in children and young adults,

and a patient may have a dozen or more at the same time.
Staphylococci are almost always responsible, except in the
perineal and perianal region, which is commonly infected
by coliforms and anaerobes. Some abscesses are
tuberculous (5.7), or from actinomycosis. In the presence Fig. 6-1 SOME SITES OF SEPSIS. Pus can gather almost anywhere,
of HIV disease, Gram-ve organisms may be responsible at but here are some of the commoner places: A, behind a child’s ear.
any site. B, in the male perineum. C, in an adult female. D, in a child.
Initially, when there is cellulitis (bacteria multiplying in
the tissues), antibiotics will be effective. Infection should WHERE THERE IS PUS, LET IT OUT
then abate within 24hrs, or develop an abscess, which
needs draining. Before pus has collected, drainage is not 6.2 Abscesses
possible. Antibiotics and drainage thus both have their
proper time and place, and you must not confuse them. The typical symptom of an abscess is severe throbbing
The tighter the space for an abscess, the more urgent the pain. The infected part is tender (dolor) and swollen
need for drainage. If a patient has pus in the bones, joints, (tumor), and the skin over it stretched, shiny, and red
tendon sheaths, or the pulp space of the fingers, draining it (rugor), although this may not be evident on pigmented
early is particularly urgent. Elsewhere, you have more skin. Touching an abscess is acutely painful. If it is large
time, but then pus may not present itself so obviously! or there are several abscesses, fever, weakness,
If pus gathers in loose tissues near the surface of the body, toxaemia, and anaemia may be present. The usual signs of
you can usually detect fluctuation. inflammation and suppuration suggest the diagnosis,
but do not necessarily expect to find fluctuation in the sites
But you will not detect fluctuation, or only detect it very where pus is in a tight compartment.
late, if pus is under tension in some tight compartment, Severe pain is a useful sign that an abscess is ripe for
or if it is inside a large fatty region such as: incision, but pain may be mild when the tissues are loose.
(1) the pulp spaces of the fingers or toes (8.5), If diagnosis is difficult, try aspirating it with a syringe and
(2) the fascial spaces of the hand (8.12) or foot (8.17), a wide bore (1·5mm) needle; but remember that pus may
(3) the ischiorectal fossae (6.17), be present even if you fail to aspirate any. Always aspirate
(4) the lobules of a woman's breast (6.13), a lump if there is the slightest hint of diagnosing an
(5) the neck or iliac regions (6.16), abscess: tubercular abscesses are often not warm, hence
(6) the parotid gland (6.10). the term ‘cold abscess’, but they are not actually cold!
Incise abscesses in any of these places without waiting for Never try to treat an abscess by one aspiration alone.
fluctuation, or for pus to point. An ultrasound scan may be useful in detecting a localized
fluid collection.

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Even if an abscess has ruptured spontaneously, EXAMINATION. Assess the general condition carefully,
adequate drainage by incision is necessary. There is no especially if there are many abscesses, or large ones.
need to curette the walls of an abscess, except in the hand Look for anaemia. SPECIAL TESTS.
where you want inflammation to resolve particularly (1);If the infection is severe, take blood cultures.
rapidly and completely. Suspect a wound abscess if a You may be able to isolate the causative organism
suture line becomes indurated and tender; it may not be (this is important in osteomyelitis).
fluctuant (11.13). (2);Test the blood or urine for sugar; this may be the first
So incise an abscess adequately and let the pus flow out; presentation of diabetes: always do this if there is more
break down any septa in a large cavity and open up any than one septic infection.
smaller cavities (loculi) off the main one. (3);If there is a particularly large or unusual abscess
(especially in the hand in the absence of trauma or
Abscesses are often placed at the end of an operating list penetrating foreign body, thyroid, muscle, abdominal wall,
of otherwise 'clean' cases, and are often left to very junior retroperitoneal space, penis and scrotum, or in the breast of
staff. They are often not treated as genuine emergencies, a non-lactating woman), or recurrent ones, test for HIV.
even though the great risk of septicaemia is ever present.
Do not therefore underestimate the seriousness of ANTIBIOTICS are not usually needed. Use them only if:
abscesses! (1);there is a severe constitutional disturbance with high
fever and toxaemia;
Nevertheless, be careful: (2);there are signs that the infection is spreading:
(1) The diagnosis can be difficult, e.g. an iliac abscess increasing erythema, cellulitis, lymphangitis, severe
(6.16). lymphadenitis, or fever;
(2) Drainage has its risks, especially severe bleeding when (3);the abscess is in the groin (a ‘bubo’)
there is a large abscess or many of them, so watch blood related to chlamydia (lymphogranuloma venereum):
loss carefully. use doxycycline;
(3) A superficial abscess over the tibia, femur, or humerus (4);the abscess is deep-seated, e,g. in the brain or liver
may turn out to be pyomyositis (7.1) or, more seriously, (15.10).
osteomyelitis (7.2).
(4) A 'chronic abscess' may turn out to be a solid tumour. DRAINAGE OF AN ABSCESS (GRADE 1.2)
Some cancers may present as infections! (24.4; 34.15). INDICATIONS. A collection of pus anywhere accessible.
(5) Do not forget the possibility of TB! If you suspect that there is a foreign body in an abscess,
this is an added reason for exploring it. Try to remove the
ULTRASOUND will readily demonstrate a collection of offending object and drain the cavity at the same time.
fluid: use this if you can when the diagnosis is unclear. If you are not sure if pus is present or not, aspirate the
lesion with a wide bore needle to see if you can withdraw
pus. If pus is present, drain it.
If you fail to aspirate pus with a needle, this does not
mean that there is no pus present!
Signs that an infection is spreading are not a
contraindication to drainage; if you suspect pus is present,
drain it.

ANAESTHESIA.
(1);You do not need muscular relaxation, so ketamine is
very suitable.
(2);If an abscess is already pointing, but the superficial
skin is not paper thin, you can infiltrate the skin at the site
of the incision with LA (6-2A). Alternatively you can
infiltrate all around circumference of the abscess, if this is
not too big.
(3);Use morphine or pethidine beforehand if the abscess is
big, or in a sensitive spot, especially for in-patients.
(4);Ethyl chloride local spray is the least satisfactory,
but you can use it for very superficial abscesses where the
skin is so thin that LA infiltration is virtually impossible.
It makes the tissues hard and difficult to incise.
(5);For babies <6-9 months a quick incision is safer
Fig. 6-2 INCISION AND DRAINAGE (I&D). (and kinder) than multiple needle pricks to establish LA or
A-C, linear incision being made and its edges spread. GA.
D-F, cross-shaped incision, cutting off the edges of the skin, and so
removing the roof of the abscess. After Hill GJ. Outpatient Surgery, WB
(6) IV diazepam with pethidine has the hazards of a proper
Saunders 1973 Fig. 5.12, with kind permission. GA and requires all the usual precautions, and has no
advantage over ketamine.

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INCISION. If the foot is infected (8.17), raise the foot of the bed.
Drain the abscess at the site of maximum tenderness and Make sure your nurses wash the abscess cavity and do not
try to follow Langer's lines (34-1E). merely put a dressing on the surface: the wound will
If an abscess is superficial, use a pointed (#11) blade then close over the cavity and the abscess will recur.
(6-2). Make sure free drainage remains possible.
CAUTION!
(1).If the abscess is deep, try to incise parallel to any DIFFICULTIES WITH ABSCESSES
nerves or vessels, not across them. If there is severe prostration without a fever,
(2).A common mistake is not to make the incision large suspect that resistance to infection is low and treat with
enough, so extend the incision the whole diameter of the particular care. Check the HIV status.
abscess!
If there are many abscesses, with pyaemia, multiple sites
HILTON'S METHOD is indicated if there is anything near of pyomyositis, or septicaemia, bleeding may be profuse
the abscess which you might possibly injure. Incise the when you drain the abscesses. For anaemia, transfuse pre-
tissues down to the deep fascia; then push blunt scissors or operatively and, if necessary, again during the operation.
a haemostat into the softest or most prominent part of the Draining multiple abscesses is a major procedure,
swelling. Open them out inside the abscess. If necessary, particularly if a child is severely anaemic or malnourished,
enlarge the wound by blunt dissection inside the tissues. so be careful before you incise too many abscesses at once
children have been known to bleed to death!
DRAIN THE PUS by putting your finger into the abscess,
and breaking down all the loculi, so that there remains If there is a huge abscess in a very ill patient, he will not
only one cavity. Use your little finger if the abscess is tolerate an extensive procedure. It may occasionally be
small. necessary to take him to the theatre several days in
If there is much pus, suck it out or clean out the cavity succession for repeated drainage slowly increasing the
with a swab. Make sure you remove all the pus: rinse the exposure.
cavity thoroughly with water: you may need to squeeze for
some time till all the pus comes out: this is painful for the If an abscess fails to heal, do not forget the possibility of
patient so use adequate analgesia. diabetes, tuberculosis (5.7) or HIV (5.6), or a combination
PROVIDE FREE DRAINAGE. Make sure that any more of these, an underlying tumour, or occasionally
pus which collects can drain from the bottom of the cavity. actinomycosis (which produces yellow so-called ‘sulphur’
granules). Check if no foreign body, e.g. part of a drain or
If the abscess you are draining has a tendency to heal suture has been left in situ.
over and leave a cavity, deroof it, (6-2F). N.B. The best instrument to find and pull out a suture
This is especially necessary with perianal (6.17) and knot in a chronically infected wound is a crochet hook!
Bartholin's abscesses. Cut away some skin, particularly
any dead skin. Allow drainage with a soft rubber drain
with a suture to hold it in place.

If pus has to drain downwards, as in the breast, try to

incise the lowest part of the abscess. This is better than
making a counter incision at its lowest point, and it also
avoids making 2 incisions.

If the drained abscess site bleeds, pack the cavity (3.1).

If necessary, infuse IV 0.9% saline. You rarely need to
transfuse blood unless there are multiple abscesses or
severe pre-existing anaemia.
Fig. 6-3 EXPLORING AN ABSCESS BY HILTON'S METHOD.
GENERAL MEASURES. If the abscess is in some A, incise the abscess at its lowest point, if this is practicable.
B, push blunt scissors or a haemostat into it. C, open the haemostat.
critical place, such as the lateral pharyngeal space (6.9), D, explore the abscess with your finger. E, insert a drain.
or the mid-palmar space (8.9), admit the patient.
Make sure the fluid intake is adequate, and do not forget to
supply an analgesic: abscesses are painful! 6.3 Pustules (Boils)
POSTOPERATIVE CARE. Rest the affected part,
and where possible raise it. For example, put the hand in a Pustules, as well as carbuncles (6.4), are contagious skin
St John's sling, or, for an in-patient, raise the hand in a infections which are usually caused by penicillin-resistant
roller towel. staphylococci. There may be a crop of them, and in a
closed community they may become epidemic.
ALWAYS INCISE AT THE POINT OF MAXIMUM
TENDERNESS

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Clean the skin round the boil with water, and cover it with If you have limited imaging facilities, your problem will
a dry dressing. Let it burst spontaneously. If it is pointing, be to diagnose an extradural abscess in the first place and
a small incision will let it discharge and will reduce the to know where it is: the abscess is underneath the swelling.
pain. You can use a sterile needle to do this. SPECIAL TESTS: The skull radiograph will only show
CAUTION! Never squeeze a pustule; especially on the changes if an extradural abscess is chronic, or if there is
face, never let the patient squeeze it. osteomyelitis of the bone. If you can perform a carotid
arteriogram (38.1), this will localize the abscess
If there are many pustules, advise washing thoroughly beautifully.
with soap and water, and to shower bd. The bath, shower
and toilets must be clean. Advise a daily change of DRAINAGE (GRADE 3.3)
underwear, and washing it by boiling. Exposure to the sun Drain the extradural abscess through a burr hole.
is one of the best cures. Avoid using ‘roll-on’ deodorants. Make this on the edge of the area of swelling on the skull
(where present), and nibble away the skull around it until
the abscess is well drained.
If the abscess is secondary to osteitis, and there is a
6.4 Carbuncles sequestrum, removing it will drain the abscess
A carbuncle is typically the result of neglected skin adequately. Likewise, if it is secondary to a neglected
infection in a dirty, malnourished, and underprivileged compound depressed skull fracture, elevation of the bone
patient, particularly a diabetic or one with HIV. fragments will locate and drain the abscess.
A staphylococcal infection starts in one of the hair
follicles, usually at the back of the neck or on the back of a
finger (8.1), and then spreads. In doing so the infection 6.6 Infections of the orbit
lifts the skin above it on a sea of necrotic fat and pus.
At presentation, pus will probably be discharging. Acute suppurative infection is common near the eye,
Antibiotics do not cure a carbuncle, although they may especially in children. It can occur in front of or behind the
stop it spreading. You will probably have to let the slough orbital septum. This is a sheet of fibrous tissue which
separate slowly, and then remove it. stretches from the edges of the orbit into the eyelids,
Be sure to test the blood or urine for sugar. Consider HIV and divides the periorbital region from the orbit. Infections
testing. of both these regions usually start acutely with erythema
If a collection of pus forms, cut down on it and drain it. and oedema of the eyelids; distinguish between them as
If the skin around the carbuncle is hairy, shave it with described below. The danger with any infection in this
as little trauma as you can. Wash it with water, apply dry region is that infection may occasionally kill the patient by
gauze, and change this frequently. A large slough will spreading to the cavernous sinus or the meninges.
form in the middle of the carbuncle. You may be able to
lift the slough off painlessly without an anaesthesic.
If the slough is slow to separate, excise it, and apply a
dressing of Vaseline (petroleum jelly) gauze.
If the bare area is large, apply a split skin graft, as soon
as it is clean and granulating.
If a black central pustule with surrounding vesicles
forms, consider ANTHRAX and treat with penicillin IV.

6.5 Extradural abscess

Pus may gather between the skull and dura as the result of:
(1) The spread of infection from sepsis nearby.
(2) Exposure of the bone as the result of an injury.
(3) Metastatic spread from elsewhere in the body.

If the abscess is large, there will be fever with signs of

Fig. 6-4 PUS IN THE ORBIT.
raised intracranial pressure (impaired consciousness and A, some important infections around the eye. B, pus spreading under
pupillary changes) and localizing motor signs, usually on the periosteum from the frontal sinus. C, pus spreading under the
the other side of the body, but not always so. Locally, periosteum from the ethmoid sinus.
there may be a diffuse inflammatory oedematous swelling (1) lachrymal gland (dacryoadenitis). (2) frontal sinus and anterior
ethmoidal air cells (sinusitis). (3) tear sac (dacryocystitis). (4) tarsal
of the scalp over the lesion (Pott's puffy tumour). If the cysts. (5) stye (hordeolum). (6) periostitis of the margin of the orbits
abscess is not so large, the only symptoms may be and suppurating tarsal cysts can occur anywhere on the lids, and
confusion. Making burr holes should be one of your basic periostitis anywhere in the orbit.
skills, so draining the pus should not be too difficult. After Dudley HAF (ed) Hamilton Bailey's Emergency Surgery, Wright
10th ed 1977 Figs 187-9, with kind permission.

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Periorbital cellulitis occurs in front of the orbital septum, Do not be frightened of operating in the orbit. Because of
is more common than orbital cellulitis and occurs in the danger of cavernous sinus thrombosis you must drain
younger children. It can be primary, or secondary to: pus early. A negative exploration will not cause harm,
(1) local trauma, (2) skin sepsis, (3) a recent upper and you are very unlikely to damage the globe.
respiratory infection often with H. influenzae (associated
RANGIT (60yrs) was admitted with a history of septic teeth for many
with bacteraemia).
years. Recently he had had fever, headache, rigors, and gradual swelling
of the mandible. He was ill, dehydrated, shocked, jaundiced,
Orbital cellulitis occurs behind the orbital septum, and is and confused. Pus discharged from his mouth, the submental glands were
less common but more serious. It is usually due to spread enlarged, the neck was stiff, and Kernig's test was postive. Both globes
were proptosed, particularly the left, which was fixed; the forehead and
from the paranasal, commonly the frontal or ethmoid,
cheek were oedematous, and the CSF turbid. Despite vigorous antibiotic
sinuses treatment he died. Postmortem examination revealed left dental and
mandibular abscesses; the left orbit and cavernous sinus were full of pus.
Subperiosteal abscesses may form when bacteria spread LESSONS (1) This is a very dangerous condition. (2) Proptosis in the
presence of facial sepsis is a sign of danger. (3) The organisms
from the adjacent sinuses.
responsible are often penicillin-resistant.

Cavernous sinus thrombosis can be: EXAMINATION

(1);Occasionally, aseptic as result of trauma, tumours, Gently separate the eyelids. Examine for induration and
or marasmus. tenderness of the lids, chemosis (subconjunctival oedema),
(2);More commonly, septic as the result of the spread of proptosis (his globe is pushed forwards), limitation of
infection from the nose (a nasal furuncle is the commonest ocular movement, and loss of visual acuity.
source), face, mouth, teeth, sphenoid or ethmoid sinuses,
the middle ear, or the internal jugular vein. A cord of RADIOGRAPHS. Infection may have spread from the
thrombus spreads from the site of the infection to the paranasal sinuses, so consider X-raying them (if this is
cavernous sinus, and sometimes to the cerebral veins and possible), to see if you can find a loss of translucency on
meninges to cause: the affected side (29-8). The films may be difficult to
(1);A rise in pressure in the veins draining the eye, interpret, especially in children in whom the sinuses are
resulting in severe oedema and proptosis. small.
(2);Paralysis of the IIIrd, IVth, VIth (commonly) and the
first 2 branches of the Vth cranial nerves. TREATMENT. If you suspect orbital cellulitis, take blood
(3) Meningeal irritation. cultures and start IV penicillin with cloxacillin or
(4);Depressed conscious level. If treatment starts late, chloramphenicol. Or, use a cefalosporin immediately!
visual impairment, ocular palsies, and hemiplegia may
result. CAUTION!
(1);Oedema and erythema of the lids are common to both
orbital and periorbital cellulitis.
(2);If the treatment of orbital cellulitis is delayed or
incorrect, cavernous sinus thrombosis may follow.

DIFFICULTIES WITH ORBITAL SEPSIS

If the globe is displaced by an inflammatory swelling,
and its movement impaired, perhaps accompanied by
loss of visual acuity, suspect a subperiosteal abscess of
the orbit. For example, an abscess above the eye will
displace it downwards. Try aspirating the pus from the
roof of the abscess with a needle. The eye may go back
into place. Then incise and evacuate the abscess through a
conjunctival fornix: the inferior fornix if swelling is
maximal inferiorly, and the superior fornix if it is maximal
superiorly. Pus will probably be coming from a paranasal
sinus and you may find the track through which pus has
spread. Insert a drain.

If there is an inflammatory swelling in the upper, outer

part of the orbit, involving the outer 3rd of the upper
lid, suspect that the lachrymal gland is infected
(DACRYOADENITIS). Incise the abscess through the
Fig. 6-5 CAVERNOUS SINUS THROMBOSIS. upper fornix of the conjunctiva, or through the eyelid.
A, orbital oedema and proptosis may be associated with paralysis of
the IIIrd, IVth, VIth (commonly), and the first 2 branches of the
Vthcranial nerves, and also with meningeal irritation. B, infection
may spread to the cavernous sinus from the eyes, nose, teeth, middle
ear, or the paranasal sinuses.

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If there is an inflammatory swelling below the medial NON-OPERATIVE TREATMENT.

aspect of the lower lid, suspect an abscess in the Treat as an in-patient with IV penicillin, ampicillin, or
lachrymal gland (DACRYOCYSTITIS). Press it; pus may chloramphenicol, as well as IV fluids and morphine or
exude through the punctum. If it suppurates, incise it pethidine. Expect a response within 24hrs: the abscess will
through the skin of the lower lid. When the infection has probably burst spontaneously, or the inflammation will
subsided, arrange for a dacryocystorhinostomy which will subside sufficiently to make drainage much easier.
usually re-establish the flow of tears.
INCISION (GRADE 1.4).
If the conjunctiva becomes increasingly congested with In the unlikely event that non-operative treatment fails, sit
bloody tears, the globes protrude, the ocular the patient upright in a chair with the head supported, and
movements become more and more impaired, a gag in the mouth. Get a very good headlight.
accommodation paralysed, the pupil fixed and dilated, CAUTION!
and the cornea anaesthetic, this is a CAVERNOUS SINUS (1) Do not allow inhalation of pus.
THROMBOSIS. It will probably involve both eyes. Early (2) Have suction instantly available.
vigorous treatment may avoid death. Use high dose IV Spray the pharynx with LA solution, such as 4% lidocaine.
penicillin with chloramphenicol or a cephalosporin, If opening the mouth wide enough is impossible, you may
together with diuretics (furosemide or mannitol) to reduce have to use GA and intubation with the head on the side as
cerebral oedema. Do not forget to deal with the cause of low as possible. Place a swab over the tongue.
the sepsis! Pack the pharynx. This can be very hazardous anaesthesia.
Have a tracheostomy set (29.15) and suction ready.
Use a guarded scalpel to incise the abscess over its most
prominent part (6-6B). Divide only the mucosa; then use
6.7 Peritonsillar abscess (Quinsy) sinus forceps to find pus by Hilton's method (6.2).

Abscesses round the tonsils are quite common, and follow If severe bleeding follows and you cannot control it,
tonsillitis. The patient, who is usually a child, has a tense try firm compression through the mouth with a tightly
swelling above and behind one of the tonsils, displacing it rolled swab. You will then be faced with a very difficult
downwards and forwards. Non-operative treatment is intubation, keeping pressure on the tonsillar fossa in order
almost always successful, and is much safer than draining to insert tight figure of 8 sutures around the bleeding
which is a heroic procedure and is seldom necessary, points.
because much of the swelling is inflammatory oedema.

6.8 Retropharyngeal abscess

Occasionally, an abscess forms in the lymph nodes behind
a child's pharynx which bulges forwards. Sometimes an
abscess is the result of infection round an impacted fish
bone. If the swelling is large enough, asphyxiation may
result. If it bursts, aspiration pneumonia may result.
The major differential diagnosis is a chronic tuberculous
abscess, which may have spread from the cervical spine.

TREATMENT
If the patient is dehydrated, correct the deficit with IV
fluids.
INCISION (GRADE 1.5)
ACUTE ABSCESS IN A CHILD.
The great danger of a GA is that the patient will inhale
pus. Ketamine is relatively safe because the cough reflex is
less suppressed. Use it IV, and keep the head down.
Have a tracheostomy set (29.15) and suction ready.
Put the child supine with the head over the end of the
table, so that the pharynx is as nearly upside down as
possible.
Fig. 6-6 TWO ABSCESSES IN THE THROAT.
A, the danger with a retropharyngeal abscess is that an unconscious
If the abscess is pointing, you may be able to open it with
child may inhale pus and get bronchopneumonia. Avoid this by sinus forceps alone. If you can get a really good view,
incising it while the head is hanging over the end of a table. you may be able to aspirate it with a needle. If this is
B, peritonsillar abscess occasionally follows tonsillitis, and may need impractical, open the abscess with a guarded knife (6-6A).
draining. Do both these incisions with a guarded knife that cannot
cut too deeply.
Put your index finger into the mouth, and slide the knife
along it. Drain it by Hilton's method (6.2), as for a
peritonsillar abscess.

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CAUTION! Do not allow inhalation of pus: (6).In the pterygomandibular space between the medial
aspirate immediately you incise. pterygoid and the ascending ramus of the mandible.
(7).In the sublingual space above or below the mylohyoid
If severe bleeding follows, and you cannot control it, muscle.
apply local pressure for 15mins. If that fails (rare), (8).In the submandibular space superficial to the
be prepared to tie the external carotid artery. mylohyoid.
(9).In the submental space in the midline under the jaw.
ACUTE ABSCESS IN AN ADULT. (10).Anywhere down the side of the neck. Do not be
Anaesthetize the mucosa over the abscess with 4% daunted by the complexity of this anatomy. Some of these
lidocaine, preferably as an aerosol, and incise it with the spaces communicate with one another and more than one
head down and on one side, as in a child. space may be involved.

TUBERCULOUS RETROPHARYNGEAL ABSCESSES Infection can spread in some particularly dangerous

(rare) are usually subacute and follow infection of the directions:
body of a vertebra. Only consider drainage if obstruction (1).From the upper jaw (or upper lip or nose) to cause
to the airway is a real danger. Drain the abscess through an cavernous sinus thrombosis, perhaps fatal (6.6).
external incision in front of the sternomastoid down to the (2).From the lateral pharyngeal space up towards the base
prevertebral fascia. Displace the thyroid gland and trachea of the skull, down to the glottis or into the mediastinum.
anteriorly, as in a cervical oesophagostomy (30-5). Infection of this space is one of the most dangerous
conditions in dentistry. There is difficulty swallowing and
speaking.
(3).From the lower jaw, via the sublingual and
6.9 Dental abscess submandibular spaces, to the tissues of the neck, where it
may cause oedema of the glottis, respiratory obstruction
The classic presentation is with a painful, throbbing, and death. This is Ludwig's angina (6.11)
swollen, red face (a 'fat face'), perhaps with fever, trismus
and lymphadenitis; this is probably an acute dental or oral
infection, most probably an alveolar abscess.
There may be:
(1) An alveolar (peri-apical) abscess: an infection which
spreads to bone from a dead tooth after suppuration of the
pulp of the tooth. There is severe pain and the tooth is
tender to percussion, and may be slightly extruded from its
socket. There is pyrexia and facial swelling develops
(and trismus if the molars are involved). If drainage is
delayed, the pus in the abscess discharges spontaneously
through a sinus (31-9) in the gum or face, which may
become chronic.
(2) A periodontal abscess at the side of a tooth, caused by
spread from an infected gum. This may cause dramatic
destruction of alveolar bone resulting in a loose tooth;
it is not usually tender to percussion.
(3) A pericoronal abscess caused by infection of the gum
over the crown of an unerupted and impacted tooth,
usually a lower 3rd molar (an infected ‘wisdom tooth’).
Often, an abscess does not form, and the gum round the
tooth is merely inflamed. Extraction of the tooth does not
promote drainage and may spread the infection.
Fig. 6-7 THE DIRECTIONS IN WHICH PUS CAN SPREAD.
Pus from all 3 of these spaces, especially the first, can A,B, views of the same structures at 90º to one another.
track in towards the cheek, the tongue, or the palate, The attachments of the mylohyoid and buccinator muscles determine
or downwards into the neck. Pus can discharge inside or whether pus, orginating in the lower jaw, points inside or outside the
outside the mouth. It can collect: mouth. A, Pus from the lower third molar spreading into the buccal
space, the submasseteric space, and the lateral pharyngeal space.
(1) On any of the surfaces of the gum ('gumboils'). B, attachments of the mylolyoid and buccinator muscles.
(2) In the buccal sulcus of either jaw on the oral or deeper The attachments of these muscles determine whether pus spreads
side of the attachment of the buccinator muscle (common). into the sublingual space, the submandibular space, the buccal
(3) On the surface of the face superficial to the buccinator sulcus, or on to the surface of the face. C, incision of an abscess in the
buccal sulcus. Partly after, Dudley HAF (ed) Hamilton Bailey's
attachment. Emergency Surgery, Wright 10th ed 1977 Fig. 151 with kind permission.
(4) On the palate (less common).
(5);In the submasseteric space between the masseter and BEWARE OF CAVERNOUS SINUS THROMBOSIS
the ascending ramus of the mandible. & LUDWIG'S ANGINA

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HISTORY & EXAMINATION. (3);Ethyl chloride local spray is suitable for an abscess
which presents on the face or in the labial or buccal sulci.
A patient of any age >5yrs has a swollen face, looking ill Isolate the infected area with gauze packs, and then spray
and distressed. He has usually had toothache in the past, on ethyl chloride until crusting occurs. Then open the
and now he tells you that he has had pain for 1wk. abscess with a #11 blade.
He has fever, trismus, and a unilateral, tender, shiny, CAUTION! Avoid GA, unless it is expert (especially if
warm, indurated swelling. Looking at him will tell you there is danger of respiratory obstruction), with intubation
which side of the face and which jaw is involved. throat packing.
Feel for warmth with the back of your index finger and test
for fluctuation. ALVEOLAR ABSCESSES.
A tooth with large holes in it probably has an apical A dentist may be able to save the tooth by draining the
abscess under it. It may be firm, but is usually loose. abscess through it, and later filling its root. If you cannot
If there are either obvious periodontal disease, refer to a dentist, remove the tooth. Many abscessed teeth
or several loose teeth, suspect a periodontal abscess. are loose, and you can then easily pick them out of their
If you are in doubt as to which of the teeth is the site of sockets.
infection, tap them with some metal object or press them Removing the tooth to allow pus to drain through the
with your gloved index finger. A tooth which is much socket may be sufficient. Do not incise a non-fluctuant
more painful than the others is probably the source of an swelling. If it is not yet fluctuant and ripe for incision,
alveolar infection. It may also be slightly raised in its use hot saline mouth washes, as hot as can be borne
socket. A tooth with a periodontal abscess is usually not without the risk of being scalded, several times a day.
tender to percussion, but often loose. Treat with cloxacillin and metronidazole and wait till the
N.B. It is quite difficult sometimes to localize the cellulitis settles.
affected tooth; be gentle and patient to be certain which CAUTION!
tooth is the offending one. It is a tragedy to remove the (1);Do not pull out the tooth (31.3) before starting
wrong tooth! treatment for peri-odontal cellulitis.
(2);If there is a tense inflammatory swelling of the
RADIOGRAPHS. If possible, X-ray the offending tooth. upper part of the neck, suspect Ludwig's angina and treat
You may see: urgently (6.11).
(1);A radiolucent area at its apex when an apical abscess
has been present for 2-3wks. PUS POINTING INSIDE THE MOUTH can point in
(2).Caries between two adjacent teeth which may not be several places:
visible from the mouth. If an abscess is pointing on the alveolus, open it into the
(3).The impacted tooth which is responsible for a mouth.
pericoronal abscess.
(4) Some other source for the infection, such as an infected If it is pointing in the labial sulcus (6-7C), make a 1·5cm
cyst, or a fracture. incision through the mucous membrane parallel to the
alveolar ridge. Push a fine haemostat into it and open the
DIFFERENTIAL DIAGNOSIS includes acute jaws.
inflammation of the salivary glands (6.10), mumps,
Burkitt's lymphoma (17.6), lymph node swellings and If it is pointing in the palate, make an antero-posterior
glandular fever, as well as snake bite, and trigeminal incision, parallel to the nerves and vessels, remove an
neuralgia. ellipse of tissue and let the pus flow out.

TREATMENT. Make sure fluid intake is adequate If there is pus in the pterygomandibular, lateral
because drinking may be difficult. pharyngeal, or submasseteric spaces, drain it through a
CAUTION! Do not apply poultices or any kind of local vertical incision inside the mouth parallel to the ascending
heat to the face: that may spread the infection. ramus of the mandible, taking care to avoid the parotid
If an abscess is pointing inside the mouth, hot saline mouth duct. This runs in the cheek under the middle ⅓ of a line
washes may ease the pain. between the tragus of the ear and the commissure of the
ANTIBIOTICS are often unnecessary, because many lips, and opens in line with the first molar tooth.
dental infections can be treated by local drainage only. Push forceps to the lingual or buccal side of the ramus,
Use IV penicillin if there is surrounding cellulitis or wherever the pus seems to be pointing. If it is under the
actinomycosis (31.6). When you have drained an abscess, masseter, insert a drain deep to this muscle down to the
culture the pus and change the antibiotic if necessary. mandible from outside the face. Insert the drain through an
CAUTION! Explain that a course of antibiotics is not incision just below the inferior border of the mandible.
sufficient treatment for the abscess, and that review is
essential, even if the swelling improves. PUS POINTING OUTSIDE THE MOUTH.
ANAESTHESIA. Drain it through one of the incisions below, as soon as you
(1);2% or 4% lidocaine spray or a swab soaked in have started antibiotics for any cellulitis present.
lidocaine solution. Removing the tooth to let the pus drain is not enough, even
(2);Inject LA solution into the outer wall of the abscess if it does drip from the root canal. If the abscess is
over the proposed site of the incision. fluctuant, it needs draining too.

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If you are not sure if it is ready for drainage or not, 6.10 Parotid abscess
insert a wide bore needle under LA. If you aspirate pus,
incise it by Hilton's method (6.2) where it points at the
softest and most tender spot. To minimize scarring, Although a parotid abscess can occur without any obvious
make an incision below the inferior border of the cause, it occurs most often in debilitated or HIV+ve
mandible, where possible. Make an incision on the face in patients, or after major surgery when mouth care has been
line with the creases in the skin. These may not always be neglected. The parotid is painful and is usually much
over the most fluctuant part of the abscess. swollen; the skin over it is tight and shiny. You may see
pus coming from the parotid duct (inside the cheek level
INCISION FOR DENTAL ABSCESS (GRADE 1.3) with the first molar tooth). Pus forms in several lobules of
CAUTION! When you plan your incision, consult 6-8 the gland between its septa, and does not form a single
and remember important features of the anatomy: abscess. This, and the division of the facial nerve into its
(1) The extension of the lower pole of the parotid gland five branches within the parotid gland, make drainage
into the side of the neck. difficult; it is however essential.
(2) The mandibular branches of the facial nerve. These run Do not wait for fluctuation.
horizontally and cross the lower border of the mandible,
just anterior to the masseter, deep to the platysma muscle
in the anterior mandibular region and deep to the fascia
posteriorly.
(3);The facial artery and vein. These enter the face from
between the submandibular salivary gland and the lower
border of the mandible; they cross the ramus of the
mandible 3cm from the angle of the jaw and then run
obliquely across the lower third of the face superficially on
the buccinator muscle. You may have to compromise
between choosing the best site for dependent drainage and
an inconspicuous scar in the crease lines of the face.
Here are some likely sites:

If there is a submental abscess, drain it through a small

midline transverse incision under the chin.

If the abscess is under the body of the mandible,

drain it through a horizontal incision 1-2cm below the
lower border of the mandible, taking care to avoid the
mandibular branch of the facial nerve and the facial
vessels. Push sinus forceps towards the lingual side of the
mandible to drain the pus there.
Fig. 6-8 DRAINING A PAROTID ABSCESS.
If the abscess points external to the buccinator, A, anatomy of the parotid gland. The facial nerve (7) enters the
drain it through a small incision over the swelling. substance of the parotid so that, if you only incise the skin and
subcutaneous tissue superficial to the gland when you reflect the flap,
you will not injure it. Note that it extends well down into the neck.
DRAINS. Suture a drain into the wound for 2-5days, Incise where the pinna meets the skin of the face and neck and
or leave it open with its edges separated by gauze. continue on in a skin crease. B, turn back the flap and incise radially
to avoid the branches of the facial nerve (7).
(1) parotid gland. (2) parotid duct. (3) border of the mandible.
For a PERIODONTAL ABSCESS, refer to a dentist for a (4) facial artery crossing the mandible about 3cm anterior to its
conservative operation, or pull out the tooth (31.3). angle. (5) facial vein. (6) incision. (7) VIIth cranial (facial) nerve.
For a PERICORONAL INFECTION (infected 'wisdom
tooth') see 31.4. INCISION. (GRADE 1.4)
POSTOPERATIVELY, after you have incised any Start incising anterior to the pinna. Keeping close to it,
intraoral abscess, treat the patient with warm mouth proceed towards the mastoid and then continue in the
washes to help the incision stay open as long as is angle between the pinna and the neck until you reach a
necessary. skin crease, then cut along this for up to 10cm. Raise a flap
of skin and subcutaneous tissue, so as to expose the parotid
DIFFICULTIES. gland. Make multiple incisions into this in line with the
If the mouth cannot open to let you get at the abscess, branches of the facial nerve. Explore each incision by
(trismus) irrigate the mouth with warm water for Hilton's method and clean out each abscess cavity with
15-20mins and try again. gauze. Close the wound with continuous or interrupted
sutures of 3/0 monofilament, leaving a dependent Penrose
drain emerging from the inferior part of the incision.

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DIFFERENTIAL DIAGNOSIS is mumps or parotid cysts ANAESTHESIA.

(17.5). There is no pus at the orifice of the parotid duct, (1);Use LA, but it will be painful and distressing so add a
mumps is usually bilateral, and the skin over the swelling little ketamine, unless the airway is almost totally
is less shiny. Mumps parotitis does not require surgical obstructed.
drainage, it resolves spontaneously. Simply aspirate (2);Do not administer an inhalation anaesthetic.
HIV-related parotid cysts. The voluntary muscles are needed to maintain the airway,
and you will be unable to pass a tracheal tube without
great difficulty.
6.11 Pus in the neck: Ludwig's angina
TREATMENT
You may see these acute suppurative infections in the This is an acute emergency: use high doses of penicillin,
neck: metronidazole and chloramphenicol IV.
(1);Suppuration in a lymph node, especially a deep
cervical one, is common in children, and is much like INCISION FOR LUDWIG’S ANGINA. (GRADE 1.4)
suppuration in any other lymph node. Make a generous incision below the angle of the mandible,
(2);Suppuration arising from an infected tooth over the point of maximum tenderness, taking care to
(Ludwig's angina) occurs in children and adults: avoid the facial artery and in the line of a skin crease if
it is a severe bilateral brawny cellulitis of the sublingual possible. The abscess will be surrounded by inflammatory
and submandibular regions, and may extend as far as the oedema. Cut through the skin and deep fascia, and explore
clavicles. It usually starts as a dental abscess in the it by Hilton's method (6.2). You may need to do some
mandible, which results in fever and severe toxicity. careful blunt dissection to release a little pus at the centre
If the infection is neglected, it may obstruct the respiration of the abscess. Do not be alarmed if you do not actually
by causing oedema of the glottis, and by pushing the find pus: it will drain spontaneously. Leave the wound
tongue up against the roof of the mouth. Anaerobes and open. If there is much bleeding, wash the wound with
spirochaetes may be responsible. Death from septicaemia hydrogen peroxide. Later, remove the offending tooth
is likely. Urgent intensive antibiotic treatment is (if this is the cause, 31.3), and when infection has settled
mandatory, together with drainage to decompress the secondarily suture the incision wound.
tissues at the floor of the mouth, even if no pus is
aspirated.
If you see chronic suppuration in the neck, think of:
(1) Tuberculous lymphadenitis (17.4),
6.12 Thyroid abscess
(2) Actinomycosis (31.6) (Acute bacterial thyroiditis)
If breathing is not significantly obstructed, you may be
wiser to wait for 24hrs for the antibiotics to act and the Abscesses of the thyroid are not uncommon in the
oedema to subside a little, before you drain the lesion. developing world, especially in the HIV patient.
If breathing is significantly obstructed, you may be Presentation is with a wide, very painful, oedematous
forced to do a tracheostomy (29.15). This is difficult, swelling of the neck which is maximal over the thyroid.
because the tissues of the neck are firm and oedematous. The pus is too deep for you to be able to detect fluctuation.
Inflammatory oedema may be so marked as to cause
Ludwig’s angina (6.11).

DIAGNOSIS. Confirm the presence of pus by needle

aspiration, if necessary under ultrasound guidance.

ANAESTHESIA. Use IV ketamine or a GA with

intubation. LA is not satisfactory, unless the pus is
pointing, but if your anaesthetist is not expert, you may
have to use it. An alternative option in this case is repeated
aspiration (preferably under ultrasound guidance).
The anaesthetist must be experienced to administer a GA.

INCISION. (GRADE 1.5) Use a scalpel to make a

transverse incision ≥5cm over the area of maximal
swelling. Insert a haemostat and drain the pus by Hilton’s
method (6.2). Insert a drain and treat with an antibiotic
(chloramphenicol or a cephalosporin) for 5days.
Fig 6-9 LUDWIG'S ANGINA.
A, note the massive swelling of the chin. B, swollen tissues have
compressed the tongue against the palate. The infection may spread
N.B. There may be perforation of the trachea, so be
to cause oedema of the glottis. prepared to aspirate the airway vigorously!
Partly after Dudley HAF (ed) Hamilton Bailey's Emergency Surgery,
Wright 10th ed 1977 Figs.153,154 with kind permission.

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6.13 Breast abscess INCISION. (GRADE 1.4) If an abscess points at the

areola, or near it, make a circumferential skin incision at
its margin. Elsewhere in the breast, a circumferential
The importance of a breast abscess is less for a mother incision is preferable to a radial one, which leaves an
than for the child, who may cease to be breast-fed as a uglier scar. In order to get a finger to break down loculi,
result of it, and develop marasmus. So your main objective the incision will have to be at least 2cm wide.
must be to see that when you have treated the abscess, CAUTION! Do not wait for fluctuation.
mother continues to breast-feed. If you are still in doubt, try to get an ultrasound scan.
Acute septic breast infections usually occur during the Cut through the skin and subcutaneous tissue. Push a long
2nd week of the puerperium, in a breast which is either haemostat into the abscess, and open its jaws.
engorged, or has a cracked nipple. Antibiotics alone are Pus will ooze out. Feel every part of the breast against the
only effective if you use them early, during the phase of haemostat, and try to enter all its loculi. Remove the
acute cellulitis. As soon as there is a definite lump or the haemostat, and use your gloved finger to break down any
presence of pus found by aspiration, incise the breast. septa between the loculi. If it is in the subcutaneous tissue,
feel for a deeper extension.
Avoid these common mistakes:
(1);Do not delay incision, and do not continue with
antibiotics alone after an abscess has formed. The mass
may fail to resolve, and become so hard (an 'antibioma')
that you cannot distinguish it from carcinoma.
(2);Do not wait for fluctuation, or for the abscess to point.
If you do, she will suffer much unnecessary breast
destruction.
(3);Provided that the mother does not present so late that
breast-feeding is impossible, do not take the baby away
from the breast unless pus is actually draining from the
nipple. A suckling baby is much the best tool to keep the
breast from being engorged.
(4);Do not suppress lactation with diethylstilbestrol;
its effects are temporary anyway.
(5) Do not forget to insert a drain.

Subacute or chronic recurrent abscesses are unrelated to

lactation, and are less painful. Frequently they are a
presenting sign of HIV disease, or the result of nipple-
piercing. They are usually close to the areola, are often
associated with inversion of the nipple, and they
commonly involve both breasts, either simultaneously,
or one after the other. A mammary fistula may be present.
Actinomycosis (31.6) or filariasis may be the cause.
If the lesion is localized, excise it (6-10).
Beware of the highly malignant condition, MASTITIS
CARCINOMATOSA, which occurs in pregnancy and
mimics breast infection (24.4). The breast is inflamed and
hard.

ANAESTHESIA. Use GA or ketamine. You should only

use LA, which is not very satisfactory, for very superficial Fig. 6-10 BREAST ABSCESS & FISTULA.
small abscesses. Be sure to add premedication with A, if an abscess points at the areola, or near it, make a
pethidine. circumferential skin incision at its margin. Elsewhere in the breast,
a circumferential incision is preferable to a radial one, which leaves
an uglier scar. B, insert your finger and break down all loculi.
ABSCESSES IN LACTATING BREASTS C, loosely pack the cavity. D, insert a dependent drain if the cavity
INDICATIONS FOR INCISION. extends below the incision. E,F, excise both ends of a mammary duct
(1);An area of tense induration. You will feel this most fistula, including 2cm of skin distal to the distal opening.
easily when the breast is empty. After Hughes LE in Rob C and Smith R, Atlas of General Surgery,
Butterworth, 2nd ed 1981 p.121 Fig.25,26 with kind permission.
(2) Pain which is severe enough to prevent sleep.
Use the tip of your finger to feel for the point of maximum
Insert a soft drain, suture it in place, and apply a dry
tenderness. Run your finger firmly across the oedematous
dressing. Wash the cavity bd. You may pack a cavity
swelling: you may feel that its centre is slightly softer than
initially if there is significant bleeding, but remove it after
its edges. If you are in doubt aspirate it with a needle (6.1).
24hrs.

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If there is a large abscess in a lower quadrant, 6.14 Axillary abscess

make a single incision in the lower part of the breast.
There is no need to make a main incision, and another
counter incision inferiorly to provide free drainage. Suppuration in the axilla can take several forms:
(1) Pus can form superficially in the apocrine glands.
If you cannot find any pus, the lesion may be an (2) It can form more deeply in the lymph nodes under
anaplastic carcinoma or the highly aggressive the pectoralis major. Open a deep abscess promptly,
inflammatory carcinoma of the young lactating woman; because pus can track along the nerve trunks into the neck.
so send a biopsy for examination. (3);It can arise in the scent glands (hidradenitis
suppurativa) as a result of the use of deodorant ‘roll-ons’
If milk flows from the wound, advise that it will stop, which block the excretory ducts.
provided breast-feeding is re-established.
CAUTION! TREATMENT
(1);If there is no fever, or throbbing pain, consider the Abduct the arm.
possibility of a carcinoma. If the abscess is superficial, incise over it.
(2) Do a careful follow-up. Another abscess may form.
DRAINAGE (GRADE 1.4)
BREAST-FEEDING must not stop! Let the baby continue If the abscess is deep, make a 3-5cm incision just behind
to suck from the normal breast and, as soon as possible, the fold of the pectoralis major, so as to avoid the axillary
from the infected breast. But do not let him suck from an vessels. Push a haemostat upwards into the swelling, open
infected breast if: its handles parallel to important structures, and open the
(1) Its nipple is cracked. abscess. Insert a drain, and suture it in place.
(2) Pus comes from it.
If so, express the milk, by hand or with a breast pump. If the whole axilla is a bag of pus, incise low in the
Discard it if it is obviously mixed with pus, otherwise axilla.
pasteurize it. As soon as the baby can fix onto the nipple,
encourage him to suck from it. If there is a large subacute or chronic abscess, consider
If presentation is late, when breast feeding has become the possibility of tuberculosis, especially if the
impossible, incise and drain the breast, and use an surrounding tissues are indurated, sinuses are present, and
antibiotic to hasten the resolution of inflammatory the breast is swollen from lymphoedema, perhaps with the
oedema. Start expressing the breast as soon as possible, sign of peau d'orange.
and follow up until breast-feeding has been re-established.
If there are multiple recurrent small abscesses in the
SUBACUTE AND CHRONIC ABSCESSES skin, the cause may be:
Be sure to take a biopsy for tuberculosis and cancer, and (1);tuberculosis, so take a biopsy. Otherwise start a
examine pus for acid, alcohol-fast bacilli. therapeutic trial with chemotherapy for tuberculosis;
(2) fungi or actinomycosis (31.6);
If there is a small opening discharging pus, at or near (3);hidradenitis suppurativa (34.9): avoid incision and
the areolar margin, or recurrent abscesses continue to drainage, and treat with cloxacillin and metronidazole or
reappear at the same site, near the areola, this is a rifampicin. Regular swabbing with surgical spirit after
MAMMARY FISTULA (or sinus). Examine the patient showering helps to open up the excretory ducts.
during a quiescent phase. See if you can pass a probe from N.B. Chronic hidradenitis results in sinuses, keloid
the site of the abscess, through to the nipple. If you can, a formation and contracture, and may need wide excision
fistula is present and you may be able to excise the whole leaving a 2cm adjacent and deep margin of soft unaffected
lesion (6-10E,F). Make the incision round the fistulous tissue.
track, and continue it 2cm distal to the fistula. There is no
need to remove more than ½cm of skin on either side of
the track. Deepen the incision to expose the underlying 6.15 Retroperitoneal abscess
tissue, and excise the fistula. Be sure to excise the central
part of the duct, because if you leave it behind, the lesion
is sure to recur. Retroperitoneal abscess is a common feature of HIV
disease; it may become very large in size because it often
If there is necrotizing fasciitis of the breast, remains undetected for a long time. It does not necessarily
there is widespread tissue destruction. This is a sign of arise from the cortex of the kidney as does the
advanced HIV disease. The options are extensive perinephric abscess. The latter is mainly staphylococcal,
debridement or mastectomy (24.5): blood loss may be but the former may have a wide variety of organisms,
extensive, so be prepared to transfuse! including salmonella and anaerobes.
The patient, who may be any age, presents with fever and
RE-ESTABLISH BREAST-FEEDING a tender swollen area in the loin or subhepatic area.
QUICKLY IN AN INFECTED BREAST If the abscess is small and related to the upper pole of
the kidney, there may be no localizing signs.

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ULTRASOUND (38.2G) is the best way of diagnosing TREATMENT. The pus must be drained. You may not
and defining a retroperitoneal collection, and can know for certain if it is perinephric, subphrenic (especially
distinguish this from a subphrenic collection. You can also in the posterior or subhepatic spaces, 10-5B), or has spread
gain information on the kidney in this way, and use from osteitis of the spine. Treat with chloramphenicol or a
ultrasound to localize where to insert a needle for cephalosporin. If you can, insert a tube drain under LA
diagnosis and a therapeutic drain. with ultrasound guidance.

RADIOGRAPHS. A plain radiograph may show POSITION. Lateral, as for a nephrostomy (27.14).
obliteration of the psoas shadow, and scoliosis with a
concavity towards the abscess. Look also for disease of the INCISION FOR RETROPERITONEAL ABSCESS.
spine, especially narrowing of intervertebral discs and (GRADE 3.2)
erosion of the bodies of the vertebrae nearby, especially The retroperitoneal abscess of HIV may become
anteriorly (osteomyelitis, an important differential so superficial that dissection is not necessary.
diagnosis). An IVU is not usually necessary; it may show a Otherwise, make a 15cm lumbotomy incision slightly
normally functioning kidney which may be displaced, below the 12th rib just lateral to the sacrospinalis muscle
especially medially or posteriorly, or a hydro- or (about the mid point of the rib) extending down obliquely
pyo-nephrosis, but ultrasound is the imaging of choice. towards the posterior iliac spine. You can extend this
laterally just above the line of the posterior iliac spine if
DIFFERENTIAL DIAGNOSIS. necessary. Take care to avoid the iliohypogastric nerve at
(1);Pyomyositis of the abdominal wall or paraspinal the lower end of the incision. Retract latissimus dorsi,
muscles. external and internal oblique and transversus abdominis
(2) Pyonephrosis. muscle origins, and cut through the deep fascia onto
(3) Subphrenic abscess. retroperitoneal fat behind the kidney. If the pus is in the
(4);Osteomyelitis of the spine, with spread to the muscles (pyomyositis), you will discover this before you
paraspinal tissues. reach the rib (unless it is in the psoas or quadratus
(5);Retroperitoneal sarcoma: this is rare, but if you incise lumborum). If it is spreading from the spine or is
into the tumour, you will lose the chance to excise it subphrenic, you will also find it.
properly. N.B. The lumbotomy incision is easier than the 12th rib
bed incision, but gives poorer access to the kidney itself;
it is, however, perfectly satisfactory for drainage of an
abscess.
Drain the pus by Hilton's method (6.2). Insert a wide bore
tube or corrugated drain and close the wound in layers.

6.16 Iliac abscess

When you see a child or young adult with a painful flexed

hip, and c.7day history of fever, anorexia, pain, and
swelling in the inguinal area, think of iliac adenitis.
The infection may have reached the iliac nodes from the
leg, the perineal area (including the genitalia), or the
buttocks. The abscess lies near the psoas muscle; this goes
into spasm and sharply flexes the hip, so that extension
beyond 90º and walking is impossible. There is a tense,
tender, hard mass in the iliac fossa, which is lower, and
closer to the anterior iliac spine, than an appendix mass.
Fluctuation is rare, and only occasionally will you find the
site of the primary infection.

It is useful to distinguish 'periadenitis' without suppuration

(common), which resolves on antibiotics and does not
need drainage, from an iliac abscess (less common), which
needs drainage and which can follow periadenitis, or
Fig. 6-11 PERINEPHRIC ABSCESS. pyomyositis of the iliopsoas, or be an extension from
A, unusually large perinephric abscess. B, approach a perinephric osteomyelitis of the spine. An appendix abscess is quite
abscess through the bed of the 12th rib. C, patient in the left lateral different, and is inside the peritoneum, whereas all these
position. D, true renal capsule is closely applied to the surface of the
kidney. Outside this, the perinephric fat is surrounded by the
other conditions are retro-peritoneal.
perinephric (Gerota's) fascia. After Flanigan RC in Rob's Operative
Surgery. 1981 Figs.1b,3,12a with kind permission.

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This condition (iliac abscess) is also known as iliac Suggesting an appendix abscess: a different anatomical
adenitis, deep inguinal adenitis, extraperitoneal iliac site: intraperitoneally in the right iliac fossa, with nausea
abscess, or suppurating deep iliac nodes. It has several and vomiting, less spasm, and only mild flexion of the hip
important differential diagnoses, and is often (14.1).
misdiagnosed.
Suggesting septic arthritis of the hip: severe joint spasm,
acute pain on percussing the greater trochanter,
no palpable mass, no movement of the hip owing to severe
pain, and a radiograph showing a widened joint space.
This is equivalent to osteomyelitis because the epiphyseal
plate is inside the capsule of the hip joint (7.18).

Suggesting tuberculosis of the hip: a chronic history and

radiograph signs of tuberculosis (5.7).

Suggesting a tuberculous psoas abscess arising from the

spine: a chronic history, radiographic changes in the spine.
A psoas abscess does not usually need drainage, unless it
is very large and causing pain. It will resolve slowly on
therapy for tuberculosis; incising it can lead to secondary
infection.

Suggesting acute and usually staphylococcal

osteomyelitis of the spine (uncommon): more pain, spasm
of the sacrospinalis, radiographic signs in the spine.
Drain the lesion as for osteomyelitis (7.2).

Other possibilities include Perthes' disease (32.14), a

slipped epiphysis, and a fracture. If the diagnosis is
difficult, and you suspect an abscess, you can: (1) Make an
examination under GA, with the abdominal muscles
relaxed. Feel the exact site of the mass and its consistency
and boundaries, and feel for fluctuation. (2) Aspirate the
mass with a large-bore needle, medial to the anterior
superior iliac spine

Fig. 6-12 A PAINFUL FLEXED HIP in an ill patient has a variety of NON-OPERATIVE TREATMENT. Deep inguinal (iliac)
differential diagnoses. A, typically the hip more flexed than is shown adenitis with periadenitis and without pus formation does
here. B, iliac abscess forms in the iliac nodes. C, exploring not require drainage. The hip is flexed as when an
extraperitoneally for iliac suppuration. D, incision for an iliac
abscess. C,D, after Dudley HAF (ed), Hamilton Bailey's Emergency abscess is present. You can feel deep tender glands above
Surgery, Wright 10th ed 1977 p.287 Fig 26.1 with kind permission. the inguinal ligament. Treat with penicillin or
chloramphenicol. If infection is slow to resolve, use skin
DIFFERENTIAL DIAGNOSIS is that of the 'sick child traction (1/7th of the body weight) to avoid contracture and
with the painful flexed hip'. It is more difficult if the right raise the foot of the bed.
hip is flexed, because the diagnosis on this side includes
appendicitis. DRAINAGE. (GRADE 2.4) If you have aspirated pus
with a needle, you can safely open up the deeper layers.
Suggesting iliac adenitis with periadenitis or an The abscess will have pushed the peritoneal lining of the
abscess: a septic lesion on the skin which may be minimal right iliac fossa medially and superiorly. Make an incision
and have healed (adenitis may appear 2wks after the 5-10cm or more over the swelling about 2cm above
primary lesion has settled), a markedly flexed hip with a the inguinal ligament, starting just medial to the
short history, a mass in the groin or right iliac fossa just antero-superior iliac spine (6-12D). Take a long haemostat
above the inguinal ligament, no pain when you percuss the and push this through the muscle over the abscess until
greater trochanter; you can flex the hip a bit more, no you find pus. Then, using your fingers, enlarge the
spasm of the sacrospinalis, and no radiographic changes. opening. Take a specimen, drain the lesion, and continue
antibiotics.
Suggesting pyomyositis of the iliopsoas: the same signs If the leg remains in spasm, apply traction as above.
as iliac adenitis. The differential diagnosis may be CAUTION! Draining an iliac abscess is potentially
impossible, and is not important because the treatment is dangerous: you may injure the caecum or the iliac vessels.
the same. So follow the method above and aspirate first.
Ultrasound guidance (38.2) will help.

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6.17 Anorectal abscess Here are the classical types of anorectal abscess, but you
may see combinations, and the diagnosis can be difficult.
Only the 1st two are common.
An anorectal abscess usually originates in an anal gland,
and may communicate through a tiny opening with the A perianal abscess presents as a red tender swelling close
anal canal, at the pectinate line. A connection between the to the anus. On rectal examination, there is little or no
skin and the anus (a fistula) is the reason why about half of tenderness, induration, or bulging in the anal canal.
these abscesses recur, or discharge persistently. There may be a fistulous track, going straight through or
Abscesses (with no opening to the skin), sinuses above the subcutaneous external sphincter, and usually
(with an opening to the skin, but not to the anus), through the lowest part of the internal sphincter.
and fistulae (with openings to both) are thus part of the
same disease process (26.3). Most abscesses settle by An ischiorectal abscess lies deeper than a perianal one,
discharging spontaneously, or being drained, but a serious is larger and further from the anus; it forms a deep tender
life-threatening infection can sometimes spread in the soft brawny swelling and is not fluctuant until late.
tissues, or deeply into the pelvis. The patient is likely to be toxic, febrile, and debilitated.
Presentation is usually acute because the pain is intense: On rectal examination you may feel a tender induration
severe throbbing pain keeps the patient awake at night. bulging into the anal canal on the same side. The infection
On examination, you find a tense tender swelling near the may spread posteriorly and then to the other side as a
anus. Sometimes, there may be little to see and no horseshoe abscess, so that there now are signs on both
fluctuation to feel, except mild tenderness at the anal sides. The presentation may then be with urinary retention.
margin, or, the whole perineum may feel tense and tender.
If the pain suddenly resolves, the abscess has probably A submucous or high intermuscular abscess (rare)
spontaneously ruptured. But there may now be a presents with pain in the rectum and no external swelling,
persistently discharging sinus or fistula opening on to the unless it is complicated by an ischiorectal or perianal
skin near the anus. abscess. On rectal examination you may be able to feel a
soft, diffuse, tender swelling extending upwards from the
pectinate line. You will often need to administer a GA to
do a rectal examination: confirm and treat the condition by
draining the abscess!

A pelvirectal abscess (rare) presents with fever,

but no local anal or rectal signs. Later, it may extend
downwards into the ischiorectal fossa. With your finger in
the anus, you may be able to feel fluctuation above and
lateral to the anorectal ring.

Do not delay treatment in the hope that an anorectal

abscess will cure itself: always incise it. If the abscess is
large, warn that it is going to take weeks to heal. De-roof it
and let it granulate. Do not try to curette it, and close it by
primary suture. A large incision will not necessarily give a
better result; recurrence depends on whether or not there is
a tiny communication between the abscess and the anal
canal.
Fig. 6-13 AN ANORECTAL ABSCESS forms in the anal glands.
The pus can track in any of the directions shown. When an abscess
bursts into the anal canal and on to the skin a fistula may form.
After Macleod JH. A Method of Proctology, Harper &Row 1979 Fig.7.9
with permission.

As anal glands are mostly posterior, most abscesses and

most fistulae are posterior. These glands extend into the
sphincters, so that pus can track in various directions:
(1) downwards to cause a perianal abscess;
(2);laterally, through the sphincters, to cause an
ischiorectal abscess. The ischiorectal spaces connect with
one another behind the anus, so that infection on one side
can spread to the other side (horseshoe abscess);
(3);rarely, medially under the mucosa of the anal canal to
Fig. 6-14 DRAINAGE OF A PERIANAL ABSCESS.
form a submucous abscess, or A, cruciate incision. B, insert your finger and break down loculi.
(4) upwards between the sphincter muscles to form a high C, wound with its edges trimmed, being left to granulate.
intermuscular abscess, or further above the levator ani
muscles to form a supralevator abscess.

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CAUTION! DRAINAGE (GRADE 1.4).

(1) If there is an acute abscess do not probe around Support the mass with your finger in the rectum.
looking for fistulae: wait until the lesion has become Make a cruciate incision the length of the diameter of the
chronic. If you probe unwisely, you may create an abscess over its most prominent or fluctuant part.
iatrogenic extrasphincteric fistula which will be very This will be externally for a perianal or ischiorectal
difficult to treat. abscess, and inside the rectum above the anorectal line for
(2) In the chronic phase, look carefully for the tracks in a rare submucous or pelvirectal abscess. Make the incision
the skin and rectum that show its presence. large enough to admit one or two fingers, so that you can
Unless you demonstrate the presence and course of the explore the abscess fully with your finger and break down
fistula, you cannot hope to cure it. all loculi (6.2). Do not break down any natural barriers to
(3) If an abscess lies anteriorly, consider the possibility the spread of infection. If possible, send a specimen of the
of a periurethral abscess in a man, or a Bartholin's abscess pus for culture. Now look again, but do not probe, to see if
in a woman. there is a fistulous opening.
(4) If there are multiple abscesses, these are likely to be
the result of inadequately draining fistulae. If you do find a fistula, which you will only find in about
10% of cases, determine where it is in relation to the
INDICATIONS FOR INCISION. Operate immediately pectinate line. Make sure there is no foreign body in the
you can feel a tender swelling. Do not wait for fluctuation. rectum.
If pain has deprived sleep, open the abscess. If the abscess is acute, you will not find a track.
Do not probe around, you may make a false track!
ZBIG (50yrs) complained of painful defecation and passing pus and
If the abscess is chronic with a well-defined wall,
blood rectally. He was found to have a perianal swelling, given a course
of antibiotics, and sent home for readmission later for examination under and the patient is well anaesthetized, probe carefully to
anaesthesia. He returned after 3 days with severe pain, swollen crepitant look for a fistula.
buttocks, and a black gangrenous scrotum. The urine was tested and was If there is no fistula, cut off the corners of the flaps to
found to contain sugar. He was referred, but died en route.
prevent the edges of the wound coming together and
LESSONS (1) Bacteria in anorectal abscesses come from the gut and
anaerobic infections can be dangerous. (2) Never treat an anorectal or adhering. A linear incision is hardly ever adequate.
perineal abscess with antibiotics without also draining it. (3) Spreading Wrap your finger in gauze and clean the walls of the
anaerobic infections originating in the gut need metronidazole and in this abscess cavity.
case at least chloramphenicol, and early debridement of all the dead
If there is a fistulous opening, pass a seton (26.3).
tissue. (4) Always test the urine for sugar and check for HIV.
Serious infections are particularly common in diabetics. Do not lay open the fistula even if it is a low type,
Recognize Fournier’s gangrene early! unless you are certain of the patient’s HIV negative status.

ANTIBIOTICS will not treat an abscess and are useful POSTOPERATIVELY, insert a soft drain, suture it in
only if there are signs of spreading infection. If so, treat place, and make sure the patient showers bd. Insert a pad
with chloramphenicol and metronidazole, and look if there inside the underwear. Recommend laxatives if there is a
are signs of necrotizing fasciitis (6.23) which needs wide tendency to constipation.
debridement. Occasionally use prophylactic antibiotics if
the patient has a hip prosthesis in situ or has had rheumatic DIFFICULTIES WITH AN ANORECTAL ABSCESS
fever. Rarely, if there is severe neutropenia due to bone If there is an abscess on both buttocks,
marrow failure, you should use antibiotics rather than use circumferential incisions 3-5cm apart on both sides
performing an incision, as in this case there will be no pus! and loop a drain between them to keep the space open
(6-15). There is sure to be a track across the midline
ANAESTHESIA. behind the anus. But be sure not to cut in the mid-line
For a large abscess, use GA or ketamine: make sure you either anteriorly or posteriorly because healing will be
put the legs up in the lithotomy position before you give very slow and you may damage the sphincter.
the ketamine, otherwise the legs may be too stiff to elevate!
N.B. LA is unsatisfactory, except for a small abscess. If there is pus draining from the anus, the abscess has
either drained internally, or there is an infected
EXAMINATION UNDER ANAESTHESIA. HIV-related anal ulcer (26.2), or other underlying disease
Use the lithotomy position. Put a finger into the anus and (e.g. tumour, amoebiasis, schistosomiasis, gonorrhoea,
feel its entire wall between two fingers (26-2F). tuberculosis, inflammatory bowel disease or trauma).
Feel if there is an indurated upward extension of the
abscess under the mucosa 3cm or more above the internal If there is an internal opening which communicates with
sphincter. Feel the extent of the abscess, and for the point the ischiorectal fossa above the anorectal ring, (rare)
of maximum fluctuation. Insert a bivalve speculum and do not cut externally, or incontinence will result!
look for pus coming out of an internal opening near the Drain the abscess internally. You may then possibly avoid
dentate line. Press on the abscess: you may see a bead of the complications of a fistula.
pus escape from the internal opening. You may feel the
opening as a localized tender depression in the anal canal
in the place suggested by Goodsall's rule (26-6I).

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6.18 Periurethral abscess

A periurethral abscess presents as a tender inflamed area in

the perineum, or under the penis. The abscess commonly
arises in the bulbar urethra, probably in Cowper’s
para-urethral glands, and is usually caused by gonococci to
begin with; but these are soon replaced by secondary
invaders. The danger is that the urine may leak from the
abscess cavity, extravasate widely, and cause extensive
cellulitis or a fistula (27.11). The urine is infected, so this
kind of cellulitis is more dangerous than that following
traumatic rupture of the urethra. There may or may not be
retention of urine due to an inflamed stricture, which will
prevent you passing a catheter, so you may have to drain
the bladder with a suprapubic cystotomy (27.8).

DIFFERENTIAL DIAGNOSES.
(1) A perianal abscess.
(2);A scrotal abscess is in a different place and is not
associated with urinary symptoms.
(3) Localized penile extravasation of urine.

ANTIBIOTICS. Use ampicillin, or chloramphenicol,

until you have the results of culture of the urine and pus,
if this is possible.

Fig. 6-15 DRAINAGE OF A HORSESHOE ISCHIORECTAL DRAINAGE (GRADE 1.4) Try passing a soft rubber
ABSCESS. urethral catheter (even if there is no urinary retention).
Incisions circumferential to the anal canal 3-5cm on both sides
without crossing the midline: a loop drain between them keeps the If catheterization is successful, drain the abscess by a
space open. Adapted from Dudley HAF (ed) Hamilton Bailey's
Emergency Surgery, Wright 10th ed. 1977 p.384 Fig 39.5 midline perineal incision; be sure to open it widely,
but take care not to damage the urethra.
If the abscess extends submucosally (rare: 6-13),
make an opening internally. Do not lay it open as it will If catheterization fails, as it probably will, and you
probably bleed copiously, and if there is untreated HIV cannot identify the urethra, perform a suprapubic
disease, it may never heal. cystostomy (27.8); then drain the abscess.

If there is a supralevator abscess (very rare), explore the If the stricture is short and the sepsis minimal, gently
abdomen and drain the abscess, preferably pass a bougie until the stricture is reached.
extraperitoneally. Open the abscess as before and feel for the bougie; display
the urethra and perform an external urethrotomy by
If there are signs of spreading infection, such as gross opening it longitudinally from the bougie distally across
inflammatory swelling, areas of necrosis, or crepitation, the stricture in order to pass the bougie into the bladder.
this is necrotizing fasciitis. Start urgent IV metronidazole Do not cut into the roof of the urethra! Replace the bougie
plus chloramphenicol or a cephalosporin and perform a by a urethral catheter. (It will then be much easier to
wide debridement. manage the stricture than if you leave it and try to dilate it
later.) Do not extend your incision in the bulbar urethra
If a fistula develops later, pass a seton (26.3) as massive haemorrhage may result, which will be very
difficult to control. Insert a soft rubber drain and
If there is a recurrent abscess (common), there is almost encourage showering bd. Manage the stricture by gently
certainly an underlying fistula. The opening may be very attempting to pass a bougie after 2-3wks.
small, and you may have overlooked it when you drained
the first abscess. Check the HIV status, and glucose. DIFFICULTIES WITH A PERIURETHRAL ABSCESS
Drain the abscess and attend to the fistula when the If the urine extravasates, treat with antibiotics and divert
infection has settled. the urine (27.12).

If there is gross faecal incontinence, If the abscess recurs, consider diabetes, HIV, tuberculosis
fashion a defunctioning colostomy to allow the sepsis to or carcinoma of the urethra.
settle, and later re-examine the remaining fistula(e).
If a fistula develops, divert the urine (27.11).

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6.19 Prostatic abscess 6.20 Abscess in the seminal vesicles

Gonococci or coliforms can infect the prostate. To begin This is rare; the symptoms are the same as with an abscess
with they cause a prostatitis, and later a frank abscess. of the prostate, but the warmth, the swelling and the
The patient presents with urgency, frequency, and dysuria, tenderness, instead of being over the prostate, are higher
or with urinary retention. There is fever, rigors, and severe and more to the side, over one, or occasionally both, of the
rectal or perineal pain, sometimes with tenesmus. seminal vesicles. There may also be pain suprapubically,
The prostate is enlarged, usually more so on one side than in the back, or down the inner side of the thighs.
the other, and is exquisitely tender. Untreated, the abscess
may burst into: DRAINAGE (GRADE 2.4).
(1) the urethra, Use an exaggerated lithotomy position, and make an
(2);the perirectal tissues, where it can present as an oblique lateral perineal incision. Dissect bluntly until you
ischiorectal abscess, feel the swollen vesicle. Push a haemostat into it, drain it,
(3) the perineum, and close the wound lightly round a drain.
(4) the rectum, forming a rectourethral fistula.

DIFFERENTIAL DIAGNOSIS.
Extreme prostatic tenderness should make the diagnosis 6.21 Penoscrotal abscess
clear. Do not confuse a prostatic abscess with:
(1);An ischiorectal abscess: the swelling is to one side of
the midline. PENILE INFECTION (BALANITIS)
(2);An abscess in a seminal vesicle: rectally, the site of Infection of opposing surfaces of the prepuce and glans
maximum swelling and tenderness will be higher and more may be the result of inadequate hygiene, incomplete
to one side. retraction of the foreskin, underlying ulceration with
chancroid, syphilis or carcinoma, or unusual sexual
SPECIAL TESTS. Test the urine for sugar, and culture it. practice.
Check the HIV status.
SPECIAL TESTS.
ANTIBIOTICS. Treat with ampicillin or chloramphenicol, Test for diabetes & HIV. Biopsy a suspicious ulcer.
until you know the results of culture.
TREATMENT
MANAGEMENT. If proper cleaning with chlorhexidine (or similar) fails,
If the prostate is not fluctuant, see what antibiotics alone either because of the severity of the infection or because
will do in 48hrs. Try to find an expert urologist, there is phimosis or underlying ulceration, use an
who can drain the abscess into the urethra with a antibiotic such as cloxacillin, and arrange circumcision
resectoscope. Otherwise drain the abscess yourself, when the inflammation has settled.
as follows. Fortunately, this is very rarely necessary.
If there is phimosis and urinary retention, perform a
DRAINAGE. (GRADE 2.4) circumcision. (27.29). A dorsal slit is not really adequate.
The ideal if antibiotics fail to cause a marked improvement
in 48hrs, or the abscess is fluctuant, is endoscopic drainage If gangrenous patches develop, this is phagedaena and
by a urologist using a resectoscope. If this is not possible, the patient becomes septicaemic. Use IV chloramphenicol
use an exaggerated lithotomy position and administer a and cloxacillin, and under ketamine, debride necrotic
GA. Start by passing a rubber Jacques catheter. tissues widely. This will involve removing the foreskin,
If this passes easily, leave it in place. If you cannot pass it, and may mean removing skin from the penile shaft also.
perform a suprapubic cystotomy. If sepsis is extensive, insert a urethral catheter in order to
show you where the urethra is and avoid damaging it
To drain the abscess, pass a metal sound, and cut down on during debridement.
to this through a 5cm midline incision immediately in front
of the anus.
SCROTAL ABSCESS
Remove the sound and control bleeding. Put your finger
through the incision into the prostatic urethra, and then If pain and swelling develop with explosive rapidity in
through its posterior wall into the abscess cavity. the scrotum and the base of the penis, with
If this contains several loculi, break down the septa hypotension, this is acute necrotizing infection known as
between them. FOURNIER'S GANGRENE (6.23).
Pack the wound loosely with a dry dressing and leave it
open, or suture the skin edges loosely over it. Remove the SPECIAL TESTS. Test for diabetes and HIV.
catheter about the 7th day.

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EPIDIDYMO-ORCHITIS & TESTICULAR ABSCESS

If chronic infection of the epididymis persists, suppuration

may result and spread to the testis itself. Alternatively
septic micro-emboli travel directly to the testis resulting in
septic necrosis. This occurs with HIV disease.
The infection is inside the scrotum rather than in the
scrotal wall; the scrotal skin is normal until the sepsis
points through. There is deep pain, which may be felt in
the abdomen.

TREATMENT
Antibiotics (usually doxycycline) may already have been
given. Explore the scrotum through a transverse incision;
if the testis and/or epididymis are severely infected,
perform an orchidectomy (27.26) and close the wound
round a drain.

6.22 Cellulitis

Infection in the fatty tissues under the skin is extremely

common, but is dangerous because it can spread easily,
Fig. 6-16 FOURNIER'S GANGRENE OF THE SCROTUM. and there is no demarcation as with pus in an abscess.
A, it is usually much worse than this. B, when it affects the penile Cellulitis can occur anywhere and is especially dangerous
shaft as well. C, healed without skin grafting, after radical in the face and orbit (6.6), or neck (Ludwig’s angina, 6.11)
debridement. After Bowesman C. Surgery and Clinical Pathology in the
Tropics, Livingstone 1960 with kind permission. but usually arises in a limb, commonly the lower leg,
which is swollen, warm and tender; later it becomes red or
This occurs with HIV disease or in diabetics shiny, frankly oedematous and increasingly painful.
spontaneously but may follow surgery to the scrotum or Erysipelas is similar, affecting the subcuticular lymphatics,
penis, or extravasation of urine, especially if infected. resulting in pustular eruptions on the skin. There is a high
It is caused by a synergistic combination of organisms, fever, which can develop quickly into bacteraemia with
including anaerobes. (Clostridium welchii is sometimes rigors.
responsible, and may form gas in the scrotum.) It spreads
rapidly, because the necrosis affects all the fascial layers, The cause is usually a small abrasion, puncture wound
dartos and tunica vaginalis together, and eats away much (especially by a thorn, metal-piercing, or conventional
of the scrotum, penis or abdominal wall, and end in surgery), blister, ulcer, burn, or infected bursa but in
Gram-ve septicaemia and death. diabetics and HIV disease, it can arise spontaneously.
Cellulitis used to be caused almost exclusively by
TREATMENT; DEBRIDEMENT (GRADE 2.2) streptococcus, but now at least 50% of cases are from
Treat with IV gentamicin, or a cephalosporin, and staphylococcus, and in HIV patients, may harbour
metronidazole. Resuscitate with IV Ringer’s lactate or Gram-ve organisms. De novo cellulitis, in the absence of
saline. Apply wet dressings and arrange debridement diabetes, is a frequent presentation of HIV, which should
immediately. (Hydrogen peroxide is effective, but quite be tested for. Actinomycosis produces a chronic cellulitis
painful.) The sloughs will probably separate rapidly to discharging yellowish granules in suitably anoxic
expose the testes. conditions.
Excise all dead tissue as soon as possible, sacrificing some
living tissue if necessary. The testes are spared, having SPECIAL TESTS
their own blood supply, and it may be necessary to expose Test the blood or urine for sugar, and screen for HIV.
both testes and leave them dangling free. You may have to
extend the debridement to the shaft of the penis and DIFFERENTIAL DIAGNOSIS
abdominal wall. Unless you remove all dead tissue in You may have difficulty differentiating cellulitis from a
severe cases, sepsis cannot be controlled and death is deep vein thrombosis (DVT): this is usually less shiny,
inevitable. Examine the wound bd, and if you see further not warm, and not so tender but the diagnosis of DVT is
necrotic tissue, do another debridement. notoriously hard: you really need a Doppler to be sure as
When the infection has settled, attempt secondary suture Homan’s sign is useless.
of the remaining elastic scrotal skin over the testes, There may even be cellulitis together with a DVT, which
or if this is not possible, just allow the wound to granulate. occurs especially in those >40yrs, after pelvic or prolonged
If there is insufficient scrotal skin left, you may have to surgery, with patients using an oral contraceptive,
bury the testes in the medial part of the thighs. and those having had prolonged air or bus travel.

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In necrotizing fasciitis (6.23), the skin is not shiny but The skin is not shiny, but dull and purplish. The necrotic
dull and purplish. fascia is greyish in colour and has lost its sheen but there is
also a telltale milky exudate separating the sick fascia from
TREATMENT. the fat. Septicaemia soon overtakes, and he becomes very
Start IV Cloxacillin 1g stat, then 500mg qid preferably; toxic, dehydrated and anaemic.
if penicillin is ineffective, valuable time may be lost trying
it out. However, the most important thing is to elevate the With certain infections, however, and typically
limb so that (for the leg), the big toe is level with the nose mycobacterium ulcerans, the necrosis is slower to develop
and (for the arm), the hand is strung up inside a sling on a and limited to subcutaneous fat and results in a
drip stand, and insist on bed rest. Once the temperature has well-defined tropical ulcer (34.9), with an undermined
come down, give antibiotics orally and when the swelling edge due to skin survival through development of
has reduced (the skin often becomes wrinkly as the collateral circulation.
oedema disappears) you need no longer continue elevating
the limb. SPECIAL TESTS
Test for diabetes & HIV. Cross-match blood if necrosis is
DIFFICULTIES WITH CELLULITIS extensive.
If sepsis persists, do blood cultures and change to a
different antibiotic, check that the patient has not been DEBRIDEMENT (GRADE 2.3)
walking around, and look for any abscess formation or Start IV gentamicin or chloramphenicol and
necrosis. Make sure any foreign body has been removed. metronidazole. Resuscitate with IV saline rapidly to
If swelling worsens with purplish discolouration and correct dehydration which is almost universal.
skin peeling, there is developed necrotizing fasciitis (6.23) Add fluconazole if you suspect mucormycosis.
and this needs urgent widespread debridement.
If there is chest pain or dyspnoea, think of DVT: Do this in the septic theatre. Excise all the affected fascia;
if this is more likely, start anticoagulants. this is inevitably more widespread than the overlying skin,
In children, cellulitis is often secondary to acute and debridement must be radical. If you leave dead tissue
osteomyelitis (7.3), which needs drilling. behind, the patient will die. (Necrosis involving the breast
In the diabetic foot, (8.17) sepsis often spreads rapidly may mean doing a mastectomy!) You may not know how
and even more so with HIV disease, resulting in far the necrosis has spread, but you must continue till no
osteomyelitis and gangrene; radical debridement with more grey fascia is found! You may lose a considerable
amputation of suspect toes is necessary. Frequently you amount of blood, so transfuse especially if he is anaemic to
will have to perform a below or above-knee amputation to start with. Irrigate the wound with hydrogen peroxide.
clear the sepsis
You will be surprised how drastically the condition
improves if you have done an adequate debridement
6.23 Necrotizing fasciitis (and how miserably it deteriorates if you haven’t).
Extend the debridement if you find more necrosis.
Inspect the wound bd, and skin graft the defect when it is
Mixed infection in the superficial and deep fascial tissues clean. You can speed up this process dramatically by using
with aerobes and anaerobes can cause extremely rapid suction dressings (11.13).
dissolution of collagen in connective tissue, gross oedema
and so interruption of blood supply to the overlying skin,
MAZHOU (36yrs) was brought to a small Mission hospital in extremis.
and fat, which necrose. Advance of infection however may He had uraemic frost, he was hardly conscious with shallow breathing,
be sudden, alarming and relentless, and its extent is greater and had necrotizing fasciitis extending from the base of the scrotum to
than at first seems apparent, particularly if there is the costal margins. Whilst intravenous saline was poured in, under
oxygen alone all the necrotic fascia was cut away: it hardly bled, and
mucormycosis (fungal infestation), which can occur in
gave off ammonia fumes! Towards the end of the procedure he started
extensive natural disasters such as volcanic eruptions. moving and needed nitrous oxide to finish the operation. The next day he
was conscious and hungry. He then explained that the scrotal swelling
It can occur anywhere: in the abdomen it is known as began after someone forcibly removed a urethral catheter that had been
inserted when he’d been admitted with cerebral malaria. He was
Meleney’s gangrene, maybe as a result of contamination
faithfully married with 3 children, and later tested HIV-ve. The urethral
from a colostomy, or in the scrotum as Fournier’s stricture was later successfully dilated, and the extensive abdominal
gangrene (6.21), maybe as a result of extravasation of wound grafted.
septic urine. However it is often spontaneous, especially in LESSONS (1) Extensive surgery is possible in extremis with no or hardly
any anaesthesia, (2) Radical debridement gives results, (3) A small
HIV disease and diabetics. The limbs, neck, chest wall
blunder gave rise to a huge problem, (4) Urethral catheterization is
and breast may all be affected; in the mouth it leads to invasive and potentially hazardous, (5) Not everyone who is moribund is
gross facial destruction (cancrum oris, 31.5). HIV+ve.

There is marked swelling and tenderness with areas of

blistering, patchy central necrosis and crepitus; the patient
is much sicker than with cellulitis, and pain extends
beyond the confines of visible inflammation.

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6.24 Gas gangrene ANY MUSCLE WOUND IS A POTENTIAL

SITE FOR GAS GANGRENE

This is an anaerobic infection of injured muscle caused by DIFFERENTIAL DIAGNOSIS Gas gangrene is not the
various species of clostridia. only cause of gas in the tissues. Air sometimes escapes
Suspect that it may occur if: into the tissues from under the skin. In ischaemic gangrene
(1) There are extensively lacerated muscles, or a missile (35.2), there is no toxaemia, unless the gangrenous tissue
wound, especially if this involves the buttocks, thighs, becomes secondarily infected. The diagnosis is usually
or axillae, or the retroperitoneal muscles following an clear.
injury to the colon.
(2) The blood supply to these parts of the body has been GAS GANGRENE: Areas at particular risk
interfered with.
(3) The wound is grossly or deeply contaminated with soil.
(4) There is prolonged dead conceptus in the uterus.

Gas gangrene is probably developing if there has been

satisfactorily progress, and then sudden deterioration.
Over 2-3hrs the patient becomes anxious, frightened,
or euphoric. The face becomes pale or livid, often with
circumoral pallor. The injured limb feels uncomfortable
and heavy. Although there may be recovery from shock
and no bleeding, the pulse rises. It quickly becomes feeble
as the blood pressure falls. There may be vomiting.
The wound may have a sickly-sweet smell of apples.

Do not let these features mislead you:

(1);There may not always be the smell of death, and even
if there is, there may not be gas gangrene.
(2);Gas in the tissues is a late sign, and even if it is
present, it does not always mean gas gangrene. One of the Fig. 6-17 MUSCLE CHANGES IN GAS GANGRENE.
muscles may be involved, or more often a group of them, A, areas which are at risk. B, as the infection advances down muscle,
its colour changes from its normal purple, through brick red and
or a whole limb, or part of it. Infection spreads up and olive green, to purplish black.
down a muscle, and has less tendency to spread from one
muscle to another. As infection progresses along a muscle, There are however 2 other conditions where the diagnosis
it changes from brick red to purplish black (6-17). is not so obvious. Both require drainage and penicillin or
At first the wound is relatively dry; later, you can express doxycycline but neither needs radical muscle excision.
from its edges a thin exudate with droplets of fat and
gas bubbles, which becomes increasingly offensive. Suggesting necrotizing fasciitis (6.23): Infection is
Stain this and look for Gram+ve rods. limited to the subcutaneous tissues, but the patient is toxic
and may be uraemic. Spread may be rapid and there may
N.B. Try to prevent gas gangrene: be much subcutaneous gas. Sometimes the whole
(1);Always perform a thorough wound toilet, especially in abdominal wall is involved. When you remove the affected
all extensive muscle wounds of the buttock, thigh, calf, tissue, the muscle underneath appears healthy, and bleeds
axilla or retroperitoneal tissues. Use plenty of clean water, and contracts normally. Remove all the necrotic tissue,
and remove dead tissues and foreign material. Never close and drain the wound.
these wounds primarily.
(2);Administer prophylactic antibiotics such as cloxacillin, Suggesting anaerobic streptococcal myositis: Spreading
gentamicin or chloramphenicol. Start immediately after the redness and swelling originating in a stinking discharging
injury for a maximum of 24hrs. There is probably no wound with Gram+ve cocci and pus cells in its exudate.
absolute need for prophylactic antitoxin serum, which is The muscles are boggy and pale at first, then bright red
probably hard to obtain, if you have performed a thorough and later pale and friable. The characteristic toxaemia of
wound debridement. gas gangrene does not develop. Make radical incisions
through the deep fascia to relieve tension and provide
Once gas gangrene has developed, do not delay exploring drainage.
the wound because there is hypotension. Radical excision
and massive doses of penicillin are the only hope. You will
be wise to excise too much muscle rather than too little.

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TREATMENT FOR GAS GANGRENE GAS GANGRENE

NURSING Isolate the patient from the other surgical

patients. If possible, barrier nurse him.

ANTIBIOTICS Treat with 10MU benzylpenicillin IV qid

for 5days. Or, use ciprofloxacin 400mg IV bd.
Culture the wound, do sensitivity tests, and if necessary
change the antibiotics. Although clostridia are not
sensitive to metronidazole, some other anaerobic bacteria
are and may co-exist in the wound, so use it.
There is no need to use ANTITOXIN.

RESUSCITATION Infuse IV saline rapidly, and keep this Fig. 6-18 SEVERE GAS GANGRENE.
running during the operation. You may need to transfuse This followed an intramuscular injection, but it could equally well
have followed a severely contaminated wound.
blood if there is severe anaemia. From a photograph, Fry,D. with kind permission of Tropical Doctor.

EXPLORATION (GRADE 1.3) Do this in a septic

theatre. Open the wound, enlarge it if necessary,
lengthwise in the limb, and cut the deep fascia throughout
the whole length of the skin incision. Excise all infected
muscle widely. Remove:
(1) Any black crumbling muscle.
(2);Any muscle which is swollen and pale and looks as if it
has been boiled.
(3):Any muscle which does not contract when you pinch
it.
(4) Muscle which does not bleed.
(5):Muscle which contains bubbles of gas. If necessary,
remove whole muscles from their origin to insertion,
part of a large muscle, or a whole group of muscles.
Remove any suspect muscle: if you leave any dead
muscle behind, he will die. Excise also any dead tissue.
Irrigate the wound with hydrogen peroxide.
Close the wound later by secondary suture, with a skin
graft or flap.

AMPUTATION If the limb is disorganized by injury or

infection, amputate it (35.3), especially if there are signs of
severe toxaemia. Take a radiograph of it first to see how
far the gas has reached. Amputate under a tourniquet.
When you have amputated, the toxaemia should improve
rapidly.
CAUTION! Close the stump by delayed primary suture,
even if you think you are amputating through healthy
tissue.

POSTOPERATIVE CARE Septic shock and/or fat

embolism may develop if it has not already done so.
Expect, and treat as best you can, the dehydration,
vomiting, delirium, jaundice, and anuria that may develop.

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In the thigh, acute osteomyelitis (7.3), guinea worm

7 Pus in muscles, infection (34.8), a haematoma, or a sarcoma (34.15).
In the calf, deep vein thrombosis, cellulitis (6.22) or a
sickle cell crisis with bone infarction.
bones and joints
7.1 Pyomyositis
Pyomyositis describes abscesses forming inside striated
muscle. It is common between 5-35yrs, especially with
HIV disease, and those debilitated by poverty, diabetes,
steroid therapy or cirrhosis. One or more muscles become
exquisitely painful, tender, and swollen, and the skin
overlying smooth and shining. A single muscle may be
involved, or a group of them, or several in different parts
of the body. The larger muscles, such as those of the
thighs, buttocks, shoulders, back, and abdominal wall are
more often involved than the smaller ones, though this
ratio seems to be reversed in HIV disease. Infection makes
them hard and indurated, so that movement is painful.
Later, the signs of inflammation may subside as the
infected muscle is replaced by pus and becomes fluctuant.
Infection of the muscle limits the movement of joints
nearby. Serious complication with fever and rigors is
common as bacteraemia ensues. Lymph node involvement Fig. 7-1 PYOMYOSITIS.
A, shows an abscess in one of the muscles of the thigh. B, the common
is not conspicuous. Septicaemia associated with sites. C, the distinction between pus in the muscles (as in
pyomyositis may be fatal and is often not diagnosed. pyomyositis), and pus between them, as in an abscess round a dead
The patient is very ill and drowsy, with a high fever, Guinea worm (34.8).
and multiple tender areas over the muscles. He may have a After Adeloye A, Davey’s Companion to Surgery in Africa, Churchill
Livingstone Edinburgh 2nd ed 1987 p143-4 Figs. 12.1,4 with kind
history of a trivial skin laceration, a blister, or a small sore. permission.
The condition rapidly progresses, so that he becomes
desperately ill with a swinging fever, weakness, DRAINAGE. (GRADE 1.4) If you are not sure if pus is
prostration, dehydration and hypotension. present or not, aspirate it with a large bore needle.
Pyaemia associated with pyomyositis results in a sequence If you are not sure where to point your needle,
of abscesses in one muscle after another. use an ultrasound to guide you if possible.
Staphylococci are responsible in 90% of cases but Make a small incision to begin with, if possible in the most
Gram-ve organisms may be found especially with HIV dependent position, and open the abscess by Hilton's
disease. Also an abscess in muscle may arise secondary to method (6-3). If it is large, extend the incision, so that you
hydatid disease (15.12), cysticercosis, actinomycosis, or a can insert your finger, break down any loculi and explore
haematoma from any injury. If streptococcus is the cause, the whole cavity. Do not use a curette. You may find >1l
the prognosis is usually worse. pus: make sure your incision drains it adequately.
SITA (38yrs) presented with fever and a vague, mild pain in her left hip, If the bone feels rough and craggy at the bottom of the
which was made slightly worse by movement. No malaria parasites were
found and no definite diagnosis was made. She was treated with abscess cavity, it may be involved; if so, this is
gentamicin and cloxacillin and her fever improved. Ten days later she osteomyelitis, not pyomyositis. Chronic osteomyelitis
returned with a huge abscess in her left inguinal region. This was incised (7.5) may develop later.
and she recovered completely. LESSON Pyomyositis may cause large
abscesses in the deeper muscles with few localizing signs
If there are signs of spreading infection (cellulitis),
treat with IV cloxacillin as well as draining the abscess(es)
DIFFERENTIAL DIAGNOSIS includes osteomyelitis
and taking a culture of the pus.
(7.2) and septic arthritis (7.16). The exact site of the
tenderness and swelling will usually lead you to the correct If there is hypotension with septicaemia, correct
diagnosis. There are several other possibilities which hydration with large volumes of saline or Ringer's lactate,
depend on the site of the abscess: and if there is severe anaemia, transfuse blood whilst you
In the upper abdomen, pyonephrosis or a perinephric drain the abscesses. Use IV cloxacillin and
abscess (6.8), a liver abscess (15.10), a subphrenic abscess chloramphenicol (2.7,8). Change these if different
(10.2), or an acute abdomen (12.1). sensitivities are reported. Do not forget to drain the
In the lower abdomen, an appendix abscess (14.1), abscesses nonetheless. If there is already coma from
an iliac or psoas abscess (6.16), a strangulated groin hernia septicaemia, do not add to the problems by using an
(18.6, 18.8), pelvic abscess (10.3) or PID (23.1). anaesthetic!

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If there is a succession of abscesses (pyaemia), However, other sites of infection are also common:
drain them as they appear, culture the pus, and treat with the proximal femur, the proximal humerus, the distal
an appropriate antibiotic as soon as you know the results radius or ulna, the distal tibia, or the calcaneus.
of culture. Treat with cloxacillin or chloramphenicol But any bone can be involved, and sometimes several of
meanwhile. Check the HIV status. them at the same time, especially in neonates where the
maxilla is often involved (7.14), and the origin
DIFFICULTIES WITH PYOMYOSITIS of the sepsis may be umbilical, pneumonic or from
If blood pours from the abscess, pack the cavity tightly gastro-enteritis.
with gauze for 24hrs. Do not curette an abscess. Metaphyses are endowed with a rich network of
It may be an infected false aneurysm (35.8); subperiosteal vessels and it appears that the primary lesion
make sure you have vascular clamps ready when you is a subperiosteal hematoma. People who walk barefoot
re-explore. and whose skin is exposed to all manner of scratches and
If there are very many or very severe lesions, thorn pricks and insect bites, people who suffer from
you may have to make >10 incisions, with repeated staged pimples, eye and ear infections and who pick their noses,
visits to the theatre, to evacuate pus and remove dead are prone to episodes of bacteraemia. Boluses of bacteria
muscle. are quickly eliminated from the circulation but devitalized
If there is overlying black necrotic skin, removing it blood is an excellent culture medium and hence if bacteria
may reveal a huge quantity of avascular greyish-pink, settle in the subperiosteal hematoma, infection will ensue
mushy suppurating muscle extending deeply underneath. and a subperiosteal abscess will develop. Pus accumulates
Remove this, taking care: (1) not to injure vital structures, under pressure, breaks out through a hole in the bone,
(2) not to lose more blood than is inevitable. Survival may and comes to lie under the periosteum. Pus then strips the
depend on aggressive (but not too aggressive) surgery, periosteum off the shaft and deprives part of the bone of its
intensive antibiotic treatment, and IV fluid replacement. blood supply, so that it dies and forms a sequestrum.
If you have had to remove much muscle, there will Although acute haematogenous osteomyelitis can be
inevitably be resulting weakness, deformity, and loss of caused by a whole array of micro-organisms,
function but you will have saved the patient’s life! If you staphylococci are by far the most common bacteria
are afraid of too much blood and muscle loss, do an implicated, salmonellae are probably the second
amputation (35.3). commonest microbes. E.coli and other enterobacteria are
If there are fever and rigors after drainage, often found with sickle cell disease or other
there is septicaemia, either from new abscesses, haemoglobinopathies.
or inadequate drainage. With HIV disease, haematogenous osteomyelitis occurs in
If abscesses are near joints and liable to develop adults as well as children, often with enterobacteria but
contractures (32.1), apply skin traction or a cast, as also with all manner of bacteria. There is little periosteal
appropriate. reaction, but osteopenia leading to bone destruction.
Before the age of 6 months, an epiphysis offers no barrier
to the spread of infection, so that pus in a metaphysis
7.2 The pathology of osteomyelitis rapidly spreads to a joint. After this age the cartilage of an
epiphyseal plate limits the spread of infection, so that a
joint is only infected if an infected metaphysis extends
Osteomyelitis is a particularly tragic preventable disease inside a joint capsule, as in the hip or shoulder.
which often disables for life if it is treated late or
inadequately. You can only treat osteomyelitis B. ACUTE TRAUMATIC OSTEOMYELITIS
satisfactorily if you treat it early. Later treatment is
difficult, expensive, and time-consuming. There are Here the organisms reach bone directly from an open
several kinds. fracture, particularly if the wound is contaminated in road
vehicle trauma, war, or a gunshot incident. The bone in
A. HAEMATOGENOUS OSTEOMYELITIS such wounds is always at risk especially if there is
The acute stage of haematogenous osteomyelitis is a inadequate wound toilet, or immediate instead of delayed
systemic disease which may be life threatening. wound closure.
It is an indicator of poverty, manifested by poor hygiene Similarly, infection can reach bone through internal
and a poor nutritional state. Typically it is an affliction of fixation of fractures, and so you must seriously weigh the
children between 4-14yrs and is more common in boys, advantages of such procedures against their risks.
probably because boys are more prone to trauma and boys
are socially allowed to be dirtier. There is often a history C. SUBACUTE LOCALIZED PYOGENIC
of minor trauma, such as being kicked on the football OSTEOMYELITIS
field, and the most commonly affected bones are the tibia
and the femur where the commonest sites of injury are the Here the infection develops insidiously from the
distal metaphyses of the femur and the proximal metaphysis of a long bone, which cavitates and produces a
metaphyses of the tibia. surrounding reactive bone sclerosis, known as a Brodie's
abscess (7-2A). Ultimately the marrow cavity is
obliterated.

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D. LATE HIV-RELATED FOREIGN-BODY E. CHRONIC PYOGENIC OSTEOMYELITIS

OSTEOMYELITIS
The stripped periosteum of acute osteomyelitis responds
Infection occurs in HIV+ve patients around metallic bone by producing new bone. Where acute osteomyelitis is
implants years after they have been inserted. inadequately treated, the bone dies and is known as a
This results in septicaemia systemically, and bone sequestrum. It behaves then as a foreign body allowing
destruction locally. The larger the implant, the greater the infection to persist. The sequestrum becomes surrounded
problem. Staphylococci are usually responsible, but you by new bone from the surviving periosteum and this new
may find many other organisms. bone is known as the involucrum. The stability of the bone
may depend on this involucrum.
Persisting infection within the sequestrum may rupture
through the involucrum producing multiple sinuses.

F. OTHER CHRONIC BONE INFECTIONS

Certain other types of chronic bone infection however do

occur, because of tuberculosis (32.3), actinomycosis,
especially in the jaw (7.14), or mycetoma (34.11). In these
there is a locally destructive process with little periosteal
reaction, in contrast to the situation with syphilis and
yaws.

7.3 Acute osteomyelitis

Acute haematogenous osteomyelitis is a surgical
emergency. It is also the supreme example of the axiom,
“Where there is pus let it out”. Your challenge is to let out
the pus before it causes pressure necrosis of the bone,
and to do so with the least possible delay. If you do not
explore an infected bone early enough, or do not explore it
at all, the patient may become severely disabled.
Early operation is not difficult; but the sequestrectomy that
may be necessary later will be very difficult.

Typically, a child from a poor family living under

unhygienic conditions presents with fever and an
exquisitely painful tender bone near a joint which he is
unwilling to move. Or, the parent may bring him to you
with fever, pain, and a limp. When you first see him the
tender area will probably not yet have started to swell.
Soft tissue swelling is a late sign which shows that pus has
already started to spread out of the bone.
Unfortunately, many children present late after they have
already sought help elsewhere. Often, the history is
atypical and may be misleading:
(1);There may be no history of an acute illness; the first
Fig. 7-2 PATHOLOGY OF OSTEOMYELITIS. sign may be a boil-like lesion which discharges
A, Brodie's abscess is an uncommon form of chronic osteomyelitis:
the upper end of the tibia or the lower femur are the common sites. spontaneously or is incised, and which is followed by a
B, initial infection in osteomyelitis typically is in the metaphysis. chronically discharging sinus.
After 6 months, the epiphyseal plates have developed sufficiently to (2);If an infant is very ill, he may have no fever and few
prevent infection spreading to the joints, except in the hip. general signs of infection.
Before this age infection spreads to the joints.
C, chronic osteomyelitis with sequestra and a sinus. D, in a baby (3);There may be signs of a severe general infection, but
<6months old, osteomyelitis is always associated with septic arthritis. few local signs.
E, osteomyelitis of the proximal femur is always associated with (4) There may be a history of a fall, suggesting a fracture.
septic arthritis, regardless of the age of the patient, because the So think of osteomyelitis in any ill child who is not using
epiphyseal line is intracapsular.
one limb.

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The only sure way to confirm or exclude osteomyelitis is Ordinary radiographs may not show any abnormality
to decompress the bone, urgently. Many doctors are only especially when the disease is early and treatable!
used to soft tissue surgery and do not like working on bone Blood tests, particularly the white blood cell count is
and look upon it as specialized orthopaedics. unhelpful, as are sedimentation rate and C-reactive protein,
The main message of this chapter is that you must for they simply suggest the presence of inflammation.
decompress osteomyelitis early!
Do your utmost to drain pus from an infected bone before DIAGNOSING OSTEOMYELITIS
it has stripped the periosteum off the shaft. After this has If a child has a high fever and is acutely tender over a
happened, the bone normally heals by forming a bone, this is osteomyelitis until you have proved
sequestrum and an involucrum, with all the disability that otherwise. If the mother tells you that there was an injury
this causes. Early treatment needs early diagnosis, up to 2wks before, this may indeed have been true in 50%
so everyone who provides primary medical care must be of cases as increased blood supply to the area may have
aware of osteomyelitis. Make sure that your staff in the been the pre-disposing factor producing the infection.
clinics know about it, and immediately refer any child with Radiographs do not help in the early diagnosis of
fever and a painful limb. Because of the common practice osteomyelitis, but they will exclude a fracture.
of giving antibiotics and seeing if the patient improves, If the tenderness is in the soft tissues, rather than over
osteomyelitis is apt to be one of the worst treated diseases a bone, this is more likely to be cellulitis or pyomyositis
in primary care. One reason why it is such an important than osteomyelitis.
disease in resource-poor settings, is that patients are so If the lower leg is swollen, oedematous, tender and
often referred to hospital late, after they have been warm, but the tenderness is not particularly localized
inadequately treated in peripheral units. over a bone, should you explore it or not? Its exact site
Any of the diseases in the list below can cause pain, fever, may help you to decide. If you are still in doubt, be safe
and inability to move a limb. Local redness and oedema and drill. You will probably operate on some cases of
are later signs. The important decision is not what the cellulitis unnecessarily, but if you do not operate, you will
exact diagnosis is, but whether you should decompress miss osteomyelitis.
bone or not. The site of the greatest tenderness (at the end If the point of maximal tenderness is over a joint, not
of a metaphysis near a joint) is a useful point of over the adjacent bone, and all its movements are
differential diagnosis, and so is the young age of the exquisitely painful, this is probably a primary septic
patient. The tenderness is localized and is greatest on arthritis. Aspirate the joint and if necessary, drain it.
direct pressure and percussion. If there is fever and an acutely painful hip which is
extremely painful to move, this is osteomyelitis of the
MURARULAL (9yrs) was brought in by the mother with a one-day neck of the femur with septic arthritis (they are in effect
history of a limp. There was tenderness over the right fibula and had a
the same disease). Aspirate to confirm that pus is present
low grade fever, but no other signs, and no radiographic changes.
The diagnosis was uncertain, so the fibula was explored. It looked normal (7.16). Drill the upper femur and its neck, and drain the
when it was exposed, but even so it was drilled. Pus came out under hip (7.18).
pressure. The wound was dressed and left open and he was given If the muscles are swollen and tender, this is probably
chloramphenicol. He rapidly improved and the wound healed
pyomyositis (7.1): feel the site of tenderness carefully.
spontaneously. A month later he had no limp and no discharge,
but a radiograph showed periosteal elevation. A year later the radiograph If sickle-cell disease is common, suspect that infarction of
was normal. the bone, which is common in this condition, may be
BUROO (8yrs) was admitted with a swelling over the upper end of her causing the symptoms if:
right tibia present for the last 4 days. A small abscess pointed. This was
(1) several of the bones are involved.
incised and drained. A week later a radiograph was taken and considered
normal. After three months of antibiotic treatment, her wound was still (2);an unusual bone is involved, such as the skull, or the
discharging, and radiographs showed obvious chronic osteomyelitis. small bones of the hands or feet, particularly if he is an
LESSON (1) If osteomyelitis is a possibility, drill the bone, especially the infant.
upper tibia. (2) Drill it even if it looks normal when you expose it.
Osteomyelitis can complicate avascular necrosis, both
If Buroo's bone had been drilled early, she would have been spared many
years of disability. (3) When you have found pus, leave the wound open. diseases may be present. There is no certain way of
distinguishing a sickle-cell crisis from osteomyelitis except
by decompression. If there is sickle-cell disease, a wait of
HIGH FEVER AND A TENDER BONE 24hrs is reasonable, because the pain of an infarct
MEAN OSTEOMYELITIS improves rapidly. Signs in a SS patient are usually obvious
clinically, but are not in SC patients (quite common in
DIAGNOSIS West Africa).
The diagnosis is clinical, except if the admitting institution If lesions in the hands are causing diagnostic
is sophisticated and in the possession of imaging difficulties, remember that:
machinery such as radio isotope scan and MRI and people (1);Tuberculous dactylitis is much less painful than
who are familiar with that machinery, a situation that will sickle-cell dactylitis.
rarely be found where this disease is common. (2);Syphilis will probably show abundant new bone
The simplest and fastest method of diagnosing a formation elsewhere.
subperiosteal abscess, and proving the diagnosis,
is aspiration, which, at the same time, will yield a
specimen.

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If the disease is some weeks old, but there are no signs

of new bone-formation on the radiograph, suspect that
this is tuberculosis, with or without HIV disease.
This is most likely to be a diagnostic problem in the spine.
Tuberculosis usually forms no new bone, whereas chronic
pyogenic osteomyelitis is more likely to. Patients with
HIV disease make very little involucrum.
If there is much swelling, but not much fever,
suspect that this may be a sarcoma, which can mimic
subacute osteomyelitis and may cause fever.
Radiographs should distinguish one from the other.
Confirm it by biopsy.
If there is a subperiosteal swelling without fever,
this may be due to scurvy or a bleeding disorder.
If there is fleeting pain in many joints, this probably is
a rheumatic polyarthritis. Rheumatic fever and
parvovirus infections are other acute and subacute causes.
If any other septic lesion, such as a carbuncle or middle
ear disease coexist, suspect this may be the source of the
osteomyelitis.
If the diagnosis is still difficult, consider brucellosis,
yaws, syphilis, and leprosy. Fig. 7-3 DIAGNOSING OSTEOMYELITIS.
A,B, critical signs: fever and painful tender bone, especially close to
an epiphysis. C, the only way to confirm or exclude osteomyelitis is
to drill the bone. If a patient comes when pus is already discharging,
PRESENTATION it is too late for an easy cure.
The presenting symptoms and signs are pain, the inability CAUTION!
(or refusal) to move the limb, fever and prostration. (1) Explore the bone (7.4), whether or not you find pus.
As long as the abscess is subperiosteal there are hardly any (2);Failure to aspirate pus does NOT exclude
local signs. osteomyelitis!

EXAMINATION. Elicit tenderness and hypersensitivity to GENERAL CARE & IMMOBILIZATION. Correct
vibration by holding a tuning fork against the bone, dehydration. Ease pain with IV analgesics. Splint the limb
even distant from the affected area. in the position of function, or use skin traction for a leg.
Look for a septic problem anywhere, but especially from a
child's skin, chest or stool from which the infection may ANTIBIOTICS. Start these immediately after you have
have spread. Culture any skin lesion, sputum and diarrhoea taken a pus swab, and if possible a blood culture also.
stool. If you have been able to drain the lesion early and it is
clinically quiescent, and there is no bone necrosis,
BLOOD CULTURES. If there is pyrexia, take a blood continue for 2-3wks. Before you know the results of
culture (if you can), and preferably 2 more at 2hrly culture, or if culture is impossible, treat with IV
intervals, before you start antibiotic treatment. If treatment chloramphenicol 10mg/kg qid, or IV cloxacillin 10mg/kg
has already started, cultures will probably be unhelpful. qid. Monitor the leucocyte count.
Treatment has 3 objectives:
RADIOGRAPHS Do not expect any signs in an early (1) to treat and prevent pain,
case. You will only see bony changes >10days in an older (2) to treat the septicemia and the associated inflammatory
child, or >5days in an infant. Examine the edge of the bone syndrome, and
with care: the earliest sign is the faintest second line of (3) to prevent the bone from dying.
new bone about 1mm away from the shaft. You will see You need to administer IV antibiotics and analgesia fast!
this more easily if you look at the film obliquely. Whilst the periosteum is relatively inelastic and cannot
Nonetheless it is useful to have a radiograph as a baseline. accommodate much inflammatory exudation, the bone is
altogether incapable to adjust to the pressure rising in the
IF YOU SUSPECT OSTEOMYELITIS, Haversian system. Therefore, as the subperiosteal lesion
DECOMPRESS THE BONE & LET OUT THE PUS! expands, the periosteum will be stripped from the
diaphysis, and as the pressure in the Haversian system
NEEDLE ASPIRATION using a 16G needle may be eventually exceeds capillary pressure, the bone will
useful in localizing pus. Unfortunately, if pus is present become ischaemic and will die. Consequently, the third
under the periosteum the disease is already advanced. objective of treatment is addressed by decompressing the
Good results are obtained by decompressing bone earlier subperiosteal abscess. At a very early stage, antibiotics
than this. Aspiration is useful for diagnosing septic alone may abort the process, but in the regions where the
arthritis, but not for treatment. condition is common presentation is usually late,
and decompression is necessary.

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If the bone looks normal, drilling holes through the If no pus or tissue fluid under pressure comes out, there
cortex of the diaphysis into the medullary cavity may in is probably no osteomyelitis, provided you really have
early cases decompress the Haversian system. drilled the tender area. If pus flows from the first hole,
The unfortunate circumstance in poor-resource settings is send a specimen for culture. Drill 1-2 more holes 1cm
that in the overwhelming majority of cases the bone, apart in a lazy zig-zag line down the shaft of the bone until
or parts of it, are dead at the time of presentation. only blood or tissue fluid flows out of the hole from
healthy bone.
If septicaemia persists, grave complications will follow:
pneumonia, endocarditis, pericarditis, and ‘metastatic’ CAUTION!
abscesses. Fortunately most patients recover from (1);Do not elevate the periosteum, because the bone under
septicaemia and if the bone has not died, the local it will die.
inflammation will subside. (2);Do not elevate too much muscle either, because
periosteum receives its blood supply from the muscles
If the bone has died, as is usually the case, pain and local over it.
signs will continue to be present. After 10-14days, (3);Do not incise the periosteum beyond the epiphyseal
a radiograph will show the extent of the dead bone: line, or you may spread the infection to the epiphysis.
this will be relatively denser than the living bone, (4) Do not remove any periosteum, because the bone under
for the living bone will have began to lose mineral density the raw area will not regenerate.
whereas the dead bone will not. (5) Never drill a row of holes transversely across a bone,
because they weaken it.
N.B. Damage to the growth plate in childhood may lead (6);N.B. A single drill hole may not drain an abscess
to stunted growth, and limb shortening or deformity. sufficiently.
(7);Do not use suction drainage, because this might suck
excessive amounts of bone marrow straight out of the
7.4 Exploring a bone for pus medullary cavity.

POSTOPERATIVELY, if there is any danger that the bone

If you suspect that there is osteomyelitis, the critical might break, apply a plaster gutter splint. In the lower
procedure is to decompress the painful tender bone. femur or upper tibia, apply skin traction. If the limb is
painful, elevate it.
DECOMPRESSION FOR OSTEOMYELITIS (GRADE 1.4) If at 2wks, the lesion is clinically quiescent,
TOURNIQUET. A bloodless field will make the operation and radiographs show no bone necrosis, stop antibiotics.
much easier (3.4). Elevate the limb first. Do not use an Otherwise continue for a maximum of 6wks. Follow up for
exsanguinating bandage, because this may spread the 3months; if the radiograph is normal then you have
infection. succeeded. Unfortunately, even early decompression is not
CAUTION! Avoid using a tourniquet on an SS or a CS guaranteed to save the bone, though you must try!
sickle cell disease patient. CAUTION! If the bone is very osteoporotic, apply a
cast before discharge to prevent a pathological fracture,
INCISION. Expose the bone on either side of the point of especially if the leg is involved.
greatest tenderness. Try to incise over a bony surface
which is covered with muscle, rather than one which is DIFFICULTIES WITH ACUTE OSTEOMYELITIS
covered only with skin. Make the incision long enough, If a child has radiographic changes on the first visit,
and start it at the epiphysis. Incise the oedematous chronic osteomyelitis will follow. Proceed as above: pus in
subcutaneous tissues. the tissues or under the periosteum will need draining.
If you find pus in the muscles away from the bone, If the child is aged <6months, osteomyelitis arising in the
do not automatically think that there is pyomyositis. metaphysis is inevitably complicated by septic arthritis.
Culture the pus. Make sure you wash the tissues with Drain the joint also. Bone necrosis is less likely, because
plenty of water, and create adequate drainage. the arteries are not end arteries.
If you do not find pus in the muscles, continue your
incision down to the periosteum. Incise it longitudinally,
and if pus immediately floods up from under the 7.5 Chronic osteomyelitis
periosteum, culture the pus and make sure there is
adequate drainage. If there is dead bone (sequestrum), the condition is
If you find no pus under the periosteum, drill a necessarily chronic. The sequestrum acts as a foreign body
minimum of 3 holes into the bone in a lazy zig-zag line, and maintains a chronic infection. In chronic osteomyelitis
starting about 1cm from the epiphyseal line and at least the general principle, that all dead tissue has to be removed
1cm apart. Make a separate small incision in the forthwith, has to be violated because removing the
periosteum for each drill hole. Drill at right angles to the sequestrum may result in destabilizing the limb.
bone, not obliquely, because drilling will be easier.

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If necrosis involves the entire width of the diaphysis

as seen on a radiograph, in order to retain a limb that
eventually can recover function, the sequestrum has to
remain in situ so that it serves as a matrix for the newly
forming bone (involucrum) that is made by the surviving
periosteum. Not only must the sequestrum be retained,
it must be kept in position to avoid a pathological fracture.
You can achieve these objectives by applying a plaster cast
or using an external fixator. You must leave holes in the
plaster corresponding to any sinuses, so these may drain.
Contrary to common practice, antibiotics are not indicated
at this stage.

The timing of the removal of the sequestrum depends on

the strength of the involucrum, but this itself may be
weakened by removing the sequestrum!

Do not remove a sequestrum until a patient has formed

enough involucrum to make a new shaft for the entire
bone. Deciding when to operate is critical.

Fig. 7-5 INSTRUMENTS FOR CHRONIC OSTEOMYELITIS.

OSTEOTOME, Swedish model, solid forged stainless steel, (a) 6mm.

(b) 10mm. Use these for cutting the bones of children. An adult's bones
are too hard to be cut by an osteotome alone. Weaken them first with a
line of drill holes.
BONE NIBBLER.
GOUGES, Swedish model, solid forged stainless steel, (a) 6mm,
(b) 10mm. These curved bone chisels must be sharp. If necessary, get
them sharpened on a grindstone. Use them for deepening a cavity in a
bone.
MALLET, stainless steel, 350g. This an adequate size of mallet, there is
no need for a larger one.
Fig. 7-4 UNTREATED OSTEOMYELITIS.
BONE FILE or rasp.
A, late osteomyelitis of the knee with a severe valgus deformity.
FORCEPS, bone cutting, Liston, angled on flat, 200mm. These are
B, destruction of the humerus causing angulation, combined with
general-purpose bone cutters. You can also use them instead of special
contractures of the elbow and wrist. C, osteomyelitis in several joints.
rib cutters.
This patient could run with simple boots after excising the exostosis,
FORCEPS, bone-holding, Hey Groves, 210m. This is for small bones,
and lengthening both the Achilles tendons. So save a patient's limb if
such as the radius.
you possibly can: amputation (35.3) is usually avoidable unless there
FORCEPS, bone-holding, Lane's 390mm. This is a heavier pair of forceps
is HIV disease.
for larger bones such as the tibia.
Kindly contributed by Ronald Huckstep.
FORCEPS, sequestrum, angled, 190mm. These are slender, angled
forceps to remove sequestra.
DO NOT REMOVE A LARGE SEQUESTRUM UNTIL CURETTE, or scoop, Volkmann, double ended, size C. Use this to curette
THERE IS A STRONG INVOLUCRUM infected bone when you operate for osteomyelitis.
LEVERS, bone, Trethowan, 220mm. Put these round a bone to expose it.
LEVERS, bone heavy, 275mm
HOOK, bone, 220mm
ROUGINE, Faraboef, with curved end, chisel edge. Use this to scrape the
periosteum from a bone.
ELEVATOR, periosteal, large.

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Surgery for chronic osteomyelitis is difficult, bloody, Encourage a strong involucrum to form by exercising the
and dangerous. If you have to operate, do so only to limb so that the newly growing bone of the involucrum is
relieve persistent pain or remove persistent sinuses, gently stressed, without being angulated or shortened.
not merely to improve the radiographs. For example, in the femur use a trunk-to-groin (hip spica)
If an area of bone is abnormally dense on the or groin-to-knee cast, add crutches and allow cautious
radiograph, showing that it is dying or dead, it may be weight-bearing.
absorbed slowly if it is attached to existing healthy bone. Occasionally there is localized sclerotic osteitis without an
But if it is lying free as a sequestrum, it will act as a involucrum (Brodie's abscess).
foreign body and will not be absorbed, so you will have to
remove it. Occasionally, you can remove a small SEQUESTRECTOMY (GRADE 2.5)
sequestrum through a sinus, but you usually need to cut a INDICATIONS. Consider removing any sequestrum
window in the involucrum. Once you have removed a which you cannot remove through a sinus. Do not operate
sequestrum, no new involucrum will form. This is an to remove a large sequestrum until:
important exception to the general rule that a foreign body (1).The involucrum extends across the defect that will
should be removed immediately, especially in the presence follow.
of infection. (2).The involucrum is made of rigid bone.
. (3).The limb must be capable of being supported, either by
the remaining healthy shaft, or by a sufficiently strong
involucrum.
CAUTION! If you remove the sequestrum too early,
the involucrum will stop making new bone, and will
collapse, so that there is no hope of a sound limb.

RADIOGRAPHS. Examine AP and lateral films carefully

to see where the sequestra are. If ordinary films do not
show enough detail inside the bone, take more with greater
penetration. Do not operate just for radiographic
appearances!

PREPARATION
ANTIBIOTICS. Culture the pus and start the appropriate
antibiotic in high dose, at induction of anaesthesia for
2-3days.
METHYLENE BLUE may help to show up sequestra
during an operation. Sterilize a 1% solution, and inject it
into the sinus 24hrs beforehand. It will stain everything
blue, except the sequestra, which will remain white.
EQUIPMENT. As for acute osteomyelitis (7.3), plus 6 and 10mm
osteotomes and gouges; 10 & 15mm chisels; a 250g mallet, a Volkmann's
scoop, a curved sequestrum forceps, and a bone nibbler. In the thigh you
will need strong retractors, a strong assistant, and a good light. Use an
ordinary electric drill (held in a sterile glove) with a rotation saw (which
you can autoclave).

TOURNIQUET. Bleeding can be alarming, because

infected tissues are very vascular, so always use a
tourniquet (3.4), unless you are operating on the proximal
Fig. 7-6 SEQUESTRECTOMY. femur or humerus, or there is sickle-cell disease (7.4).
A, sequestrum presenting through a cloaca (hole) in the bone. The anatomy may be very distorted, and without a
B, enlarge the cloaca and remove the sequestrum.
Kindly contributed by John Stewart.
tourniquet, important structures will very difficult to
recognize. Tie any vessels you see as you operate.
Antibiotics will not produce a cure. So, explore, curette, Have blood cross matched, and infuse IV fluid.
and if possible saucerize the cavity (i.e. obliterating the
cavity by making the hole flat). This will relieve the pain INCISION. The choice of incision will depend on the
dramatically. If possible, leave it open to the outside, and anatomy of the sequestrum, the involucrum and the neuro-
let it granulate from the bottom. If not, leave it open to the vascular structures of the limb. (The tibia is best
soft tissues. approached antero-medially, the femur laterally).
When you have removed a sequestrum, there may be a Start by probing any sinuses to see where they extend.
defect in the soft tissues or skin; if the wound granulates, They often join up. Where possible, make one of the
you can place a skin-graft over it. Otherwise he may need standard incisions described. These are given for the entire
a complex flap. length of the bone.

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You will usually only need part of an incision. Very often After some weeks there will be a floor of healthy
it will include the draining sinuses. If possible, make the granulation tissue, which will either epithelialize
incision over one of the larger gaps in the involucrum. spontaneously, or can be grafted. As you change the
The tissues will be tough, so use a sharp scalpel. dressings you will find that fewer are needed as it closes.
Open the indurated periosteum in the length of the A large wound takes a long time to close.
incision, and elevate it on each side. You will have to CAUTION! Remove all the dressings you put into a
make a hole by chisel or drill and rongeur in the wound. If any fragments remain, they will act as foreign
involucrum so that you can extract the sequestrum. bodies, and cause infection to persist. If you use pieces of
Either: enlarge an existing gap in the involucrum with a gauze to pack a wound, knot them together, so that you
gouge. Or: drill holes so as to outline a window (7-6). can pull them all out at the same time.
Then open it with an osteotome.
CAUTION! POSTOPERATIVELY, the wound will ooze. Do all you
(1) Scar tissue may have disturbed the normal position of can to improve nutrition. You will need quantities of
the nerves and arteries. sterile dressings. Change them regularly. Remove any
(2) Do not break the bone. If you have carefully outlined dead tissue as necessary. After you have removed all the
the window with drill holes, this will be less likely. dead tissue, the disease process comes to an end and
Use a hammer and gouges or chisels to cut bits of bone rehabilitation can begin. Encourage use of the limb,
from the involucrum until you get to the marrow cavity. walking with crutches without weight-bearing if the lesion
Look for sequestra inside it. was in the leg, and the use of the arm as much as possible.
In severe cases this active movement will encourage the
SEQUESTRA move separately from the surrounding periosteum to produce a really robust involucrum, which
involucrum. If they have been covered by tissues they are will not happen if the limb remains completely immobile.
ivory white and have a brittle texture which is different If the involucrum might fracture, apply a cast and
from ordinary bone. If they have been exposed to the air window it. Or, in the leg, apply skin traction. If a large
they may be black or grey. area of bone has been destroyed, careful splinting is
Sometimes it is necessary to break the sequestrum and essential.
remove it piecemeal. To prevent the bone splitting, Get radiographs at a convenient time postoperatively.
use a drill with a rotation saw instead of a hammer and This is only necessary to assess the strength of the leg for
gouge to chip away the involucrum around each weight bearing, or, if sinuses persist, to look for more
sequestrum so that you can remove it. To minimize sequestra.
weakening, make a window in the bone longitudinally.
Round or taper the ends of the window; these will be DIFFICULTIES WITH CHRONIC OSTEOMYELITIS
stronger and allow it to fill with soft tissue more easily. If there is severe bleeding into the dressings,
Pull out sequestra with sequestrectomy forceps. return to theatre, open the wound, tie off any bleeding
If necessary, remove more involucrum to free a vessels, repack it tightly, and apply a pressure bandage.
sequestrum. There will be pus, but usually not much. Back in the ward raise the limb, and put a cradle over it, so
When you have removed all the sequestra you can find, that you can inspect it readily. Do not leave a pressure
explore the abscess cavity up and down quite widely with dressing in place for >48hrs, or it will promote infection.
a probe. If necessary, extend the skin incision and enlarge If pus continues to discharge from the wound,
the hole in the involucrum until you have explored the it may be due to:
whole cavity. Scrape the granulation tissue in its walls (1).Inadequate excision of fibrous tissue and curettage of
with a bone curette (Volkmann's spoon), until you reach the granulations.
bleeding healthy bone. If sinus tracts in the soft tissues are (2) Leaving sequestra behind.
short, excise them. If they are long, curette them. (3).Leaving a swab or piece of dressing in the wound.
If bone overhangs the edge of the cavity, chisel it away. (4) Not opening up the cavity in the bone widely enough.
Lavage the cavity with warm water. If the leg has malunited in a deformed position,
CAUTION! If the operation is to succeed, you must an osteotomy may be necessary.
remove all sequestrated bone. The radiographs will If there is a pathological fracture, splint the limb in the
suggest how much there is, but expect to find more. correct position in a cast until it has healed soundly. While
Allow muscle to fall into the cavity (7-10); if this is it is healing pay special attention to the alignment of the
inadequate, mobilize a flap of muscle, preserving its blood knee and ankle. Keep the wound open, dress and toilet it
supply, to fill the cavity. regularly. Skin traction is suitable for the femur and upper
tibia, especially <14yrs. Otherwise an external fixator is
CLOSURE: Complete meticulous haemostasis is essential. best.
A suction drain may be beneficial to avoid accumulation If osteomyelitis has followed internal fixation with a
of blood. Fix the drain to the wound with a stitch, because plate, remove it. The only exception is an AO
it may fall inside the wound, get lost, and act as a foreign compression plate. If this is still maintaining compression,
body. leave it, but if it is holding a gap open between the
Apply a pressure dressing for the first 48hrs, but watch the fractured ends, remove it.
circulation distally.

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In an infant, the bone will probably heal well, even after If necessary, you can split the brachialis to within 3cm of
you have removed a large sequestrum. If an operation is the epicondyles without entering the elbow joint.
needed, do not hesitate to operate as soon as a satisfactory Do not extend the incision beyond the flexor crease of the
involucrum has formed. elbow, because you may cut the radial artery.
If there is sickle-cell disease, new bone will form
particularly slowly.

AMPUTATION (35.3) is justified if:

(1);The infection is so extensive that antibiotics and
surgery have been unable to arrest the disease.
This is usually the case with HIV-related osteomyelitis.
(2) Life is in danger from infection.
(3) So much bone has to be removed that the leg is useless.
(4) There is constant pain.
(5);There is no chance of referring the patient for
cancellous bone implantation to reconstruct the leg.

7.6 Osteomyelitis of the humerus

Osteomyelitis usually occurs at the ends of the humerus,

more often at the upper than the lower end.
You can expose and drill the bone through quite limited
incisions; the upper end anteriorly and the lower end either
anteriorly or posteriorly. If absolutely necessary,
you can expose the humerus from end to end by
approaching it from the antero-lateral side.
The main danger is that you may injure the radial nerve,
as it winds round the humerus posteriorly. If you are
working near it, find it first so that you can avoid it.
Proximally, enter the arm between the pectoralis major
and the deltoid. Distally, enter it between the
brachioradialis and the biceps. As you do so, retract the
radial nerve laterally, and the musculo-cutaneous nerve
medially with the biceps.

PROXIMAL END. Approach this in the deltopectoral

groove. Find the cephalic vein, and try to displace it
medially. If necessary, tie it proximally and distally.
Reflect the deltoid laterally, and expose the humerus by Fig. 7-7 OSTEOMYELITIS OF THE HUMERUS.
using two pairs of bone levers. Both the heads of biceps, A, approach for the upper end. B, anterior approach to the lower
and coracobrachialis lie medial to the insertion of the end. C, posterior approach to the lower end. D, incisions to approach
the ends of the bone. E, cross section a little below the mid-point of
tendon of pectoralis major. the arm above the origin of brachioradialis, to show the approach to
the middle of the shaft and the position of the radial nerve.
DISTAL END, POSTERIOR APPROACH. Make a
midline incision in the posterior surface of the upper arm, THE SHAFT. Put a sandbag under the shoulder on the
and end it 3cm above the epicondyles, so as to avoid the same side. Drape the whole arm. Extend the approach to
olecranon pouch. Do not extend the incision up into the the upper humerus distally, or the lower anterior approach
middle third of the arm, or you will injure the radial nerve. proximally. Distally, divide the deep fascia to expose
Divide the tendon of the triceps and the muscle under it to division between biceps and brachialis. The musculo-
expose the humerus. cutaneous nerve lies between these muscles. Displace it
medially with the biceps. Separate the biceps and
DISTAL END, ANTERIOR APPROACH. Open the arm brachialis and find the radial nerve. Above the origin of
between the brachioradialis laterally, and the biceps the brachialis, it lies between biceps and triceps and winds
medially (7-7B). Separate these muscles by blunt posteriorly round the humerus in the radial groove.
dissection, find the radial nerve and leave it laterally. Postoperatively, put the arm in a sling and encourage
Incise the brachialis medial to the nerve and expose the active movements within the confines of the sling, or
humerus. Retract the muscles by placing two pairs of bone apply a backslab.
levers subperiosteally.

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7.7 Osteomyelitis of the radius DISTAL END

Lay the patient supine with the arm on a side table and the
forearm supinated. Define the line of the incision by
You can expose the distal ⅔ of the shaft of the radius by identifying the tendons of the palmaris longus and the
approaching it from its anterolateral side. The difficult part flexor carpi radialis at the wrist. Incise just lateral to this
is its proximal ⅓, which is covered by the supinator muscle (7-8B).
muscle, through which the posterior interosseous nerve You will probably only need to incise over the distal ⅓ of
passes. So avoid operating here if you possibly can. the bone. If necessary, you can continue the incision
Enter the forearm between the brachioradialis laterally proximally to include its middle ⅓.
(it has a characteristic flat broad tendon) and the flexor CAUTION! Do not extend the incision to the proximal
carpi radialis medially. The radial artery lies between ⅓, or you may injure structures on the front of the elbow.
these 2 groups of muscles. Pronator teres is inserted into
the middle of the radius. You can approach the bone on Cut the deep fascia in the line of the skin incision.
either side of this muscle, and displace it medially or Tie any vessels you meet. Retract laterally the 3 muscles
laterally. Distally, pronator quadratus covers the radius, that lie along the lateral border of the forearm:
so you will have to divide it. brachioradialis, extensor carpi radialis longus and brevis.
When you retract them, the superficial radial nerve will be
included with them. This is sensory only.
Find the radial artery and vein, which lie between the
lateral group of muscles and flexor carpi radialis.
Retract them laterally. You will now have exposed the
anterolateral surface of the distal ⅔ of the radius.
Postoperatively, apply plaster only if a fracture threatens
or has occurred. If so, apply a tubular forearm cast leaving
the wrist and elbow free. The remaining bone will prevent
angulation. Encourage use of the arm.

7.8 Osteomyelitis of the ulna

The ulna has a subcutaneous border throughout its whole

length, so it is easy to expose.
Make an incision anywhere from the tip of the olecranon
to the ulnar styloid. Use the most appropriate part of the
incision (7-8D), not all of it. Cut straight down on to the
shaft of the bone and elevate the periosteum.
This will carry the muscular origins of the flexor carpi
ulnaris anteriorly, and those of the extensor carpi ulnaris
posteriorly.
Postoperatively, apply plaster only if a fracture threatens
or has occurred. If so, apply a tubular forearm cast leaving
the wrist and elbow free. The remaining bone will prevent
angulation. Encourage use of the arm

7.9 Osteomyelitis of the femur

If osteomyelitis is acute, you need only drill the upper or

lower end of the femur, for which you will only need a
limited incision. If osteomyelitis is chronic, it may have
involved the entire shaft of the bone. By a lateral
Fig. 7-8 EXPOSIN THE RADIUS AND ULNA. approach, you can expose it from its greater trochanter to
A, cross-section of the forearm at the level of the radial tuberosity. its lateral condyle. Cut straight through the vastus lateralis
B, to expose the radius, enter the forearm between the brachioradialis
and the two radial wrist extensors laterally, and the flexor carpi
down to the bone. The head and neck of the femur are
radialis medially. C, a transverse section through the middle of the more difficult to reach. If osteomyelitis has involved the
arm. D, the ulna is subcutaneous, so you can approach it easily. neck, which is partly inside the capsule of the hip joint,
E, brachioradialis has a long flat tendon, so you can recognize it it will have also involved the head and the hip joint.
easily. It and flexor carpi radialis flank the incision for the lower part
of the radius. Partly after Watson-Jones R, Fractures & Injuries, E&S
This will need draining. The anterior approach is easiest
Livingstone 1960, with kind permission. for drilling the femoral neck (7.18).

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Osteomyelitis of the femur commonly involves the hip If there is bleeding from the vessels of the linea aspera,
joint, and occasionally the knee, but seldom both. catch them with a haemostat, and transfix them with a
When a child's knee is involved, the distal femoral ligature on a curved needle. Pass the needle round under
epiphysis may slip. If this happens, the shaft of the femur the haemostat and the vessels at least twice.
usually slips anteriorly in front of the distal epiphysis, Pull the ligatures tight as you release the haemostat.
unlike in injury in which it slips posteriorly. They are usually too deep into the wound to tie on the tip
Prevent further slipping by applying skin traction up to the of a haemostat. If you cannot reach a bleeding vessel, pack
mid thigh. You may need to manipulate it under GA. the wound tightly, raise the foot of the table and wait for
the bleeding to stop.
If you are operating towards the distal end of the
femur:
(1) Do not enter the knee joint or the suprapatellar bursa.
(2) Stay strictly on the lateral side of the knee.
(3);Do not go posteriorly: you may injure the lateral
popliteal nerve.
(4);Do not go medially because you may injure the main
vessels.
Postoperatively, apply skin traction. This will be easier
than applying a medial plaster splint, which is the
alternative. Later, use a hip spica or a plaster cylinder from
the groin to the knee, add crutches, and encourage weight-
bearing.

7.10 Osteomyelitis of the tibia

The tibia is one of the most common sites for

osteomyelitis, which is fortunate, because it is one of the
easier bones to approach. If the infection is early,
Fig. 7-9 EXPOSING THE FEMUR. decompress it through a short incision. If chronic infection
You can expose the femur by cutting straight down onto it along the
lateral side of the thigh. A, prop up the buttock on a sandbag, and exists, do not operate before a firm involucrum has
secure the patient on the operating table so he does not fall off! formed, or you will leave a gap in the bone which will
B, expose the middle ⅓ of the femur. C, cross-section of the middle of need extensive reconstructive surgery to repair.
the thigh. D, cross-section about 4cm above the adductor tubercle. A gap is particularly likely in the tibia, because so much of
Kindly contributed by John Stewart.
it is subcutaneous.
DRILLING. Make a linear incision 1cm lateral to the
THE SHAFT OF THE FEMUR
anterior border of the patient's tibia (7-10):
Cross-match two units of blood; this can be a bloody
operation, especially if you cut too far posteriorly.
Use the supine position with a sandbag under the hip on
the infected side. Use a tourniquet when you operate on
the middle or distal thirds of the bone.
Cut along the relevant part of the incision (7-9A).
This extends from just distal to the greater trochanter to
just above the lateral femoral condyle. Cut through the
skin, subcutaneous fat, and fascia lata. Then cut straight
through the vastus lateralis, down to the lateral side of the
shaft of the femur. There will be some bleeding, but much
less than there would be if you cut posteriorly on to the
linea aspera.
CAUTION!
(1) Take care to stay on the lateral surface of the femur.
(2);Avoid the linea aspera, and vessels near by.
(3);Remember that blood loss in a small child is
proportionately more serious.
Fig.7-10 OSTEOMYELITIS OF THE TIBIA.
A-B, expose the upper end of a patient's tibia. Incise over muscle on
the lateral side. C-D, expose the lower tibia; again incise over muscle
on the lateral side. E-G, expose the shaft of the tibia. Incise mainly on
the lateral side and reflect a flap medially. H-I, allow the edges of the
flap to fall into the wound to close it postoperatively.

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SEQUESTRECTOMY. Make the main part of the 7.11 Osteomyelitis of the fibula
incision over the muscles rather than the bone.
Make the longitudinal part of the incision 1cm lateral to its
anterior border. Proximally, do not extend it higher than Osteomyelitis of the fibula is uncommon. If the tibia is not
the tibial tubercle. If possible, avoid taking it across the involved, you can remove a sequestrum from the fibula as
tibia where this is infected, because the scar from the soon as is convenient, without waiting for an involucrum
incision will stick to the bone and become painful later. to form, because the tibia will support the leg.
If necessary, curve its upper and lower ends to cross the You can expose any part of the fibula by approaching it
anterior border of the bone. between the peroneal muscles anteriorly and the soleus
Reflect the skin with the periosteum. They will probably posteriorly. The posterior tibial nerve and vessels are well
be so closely bound together that you will be unable to out of harm's way; but be careful not to injure the peroneal
separate them. Hold the skin flap lightly with skin hooks. artery and veins which are close to the postero-medial
Incise the periosteum midway between the anterior and angle of the shaft of the fibula. If the head of the fibula is
posteromedial borders of the bone. involved (rare) be very careful not to injure the common
If the position of sinus tracks are medial, you can make peroneal nerve.
a medial flap in the same way, with most of the length of
the incision over the muscle on the medial side of the tibia.
After you have removed the sequestrum:
(1) If the tissues are not too tight, close the wound lightly
and insert a drain in its lower part.
(2) If the tissues are tight, let the skin edges fall into the
wound and leave it unsutured (7-10H,I). Healing will take
longer like this. Apply a posterior slab or a long leg cast
with the ankle in neutral, and the knee in 20º of flexion.
Mark a window in it while it is still soft, cut out the
window with a knife, or with a plaster saw 2days later
when it is hard. Dress the wound through this window.
If you have left a deep trough in the front of the tibia
which is slow to granulate and epithelialize, graft it.
CAUTION!
(1) Do not go directly anteriorly through the subcutaneous
surface of the tibia.
(2) Make sure your assistant retracts the skin flaps gently,
because they can easily necrose.
Apply a long leg cast with a walking heel, then encourage
early weight bearing with as normal a gait as possible.

DIFFICULTIES WITH OSTEOMYELITIS OF THE TIBIA

Fig. 7-11 OSTEOMYELITIS OF THE FIBULA.
If there is a very large skin defect in the tibia which is Approach the fibula between the peroneal muscles anteriorly,
slow to heal, consider making relieving incisions about and the soleus posteriorly.
15cm long down the medial and lateral sides of the calf,
and pushing the tissues forward to cover part of the gap. INCISION. Use the lateral position with the affected
Hold them in place with sutures or strapping. Graft the gap leg uppermost, and the knee slightly flexed.
made by the relieving incisions. Use the appropriate part of an incision which starts 5cm
below the head of the fibula, and curves gently posteriorly
If a large part of the tibia has been destroyed, and down towards the lateral malleolus. Reflect short skin
inadequate involucrum has formed, try to get the fibula flaps anteriorly and posteriorly. Avoid the head and neck
to hypertrophy. Apply a below-knee calliper. Later, an of the fibula, because the common peroneal nerve winds
operation in which a length of the fibula is moved across round it. If you have to remove sequestra from the head,
to form a new tibia is needed. This is done in two steps, try to pull them down from below.
moving one end at a time. The transposed piece of the If you are working on the middle ⅓ of the fibula, incise
fibula can hypertrophy greatly. the periosteum vertically, and separate muscle from bone
subperiosteally.
If: (1) a sequestrum was removed before a firm CAUTION! The peroneal vessels are close to the medial
involucrum had formed, or side of the fibula, so strip the muscles carefully.
(2) the periosteum in the middle ⅓ of the shaft of the
tibia is destroyed, use a Sarmiento cast, to support the leg EXCISION OF THE FIBULA. (GRADE 2.5)
and prevent the foot going into inversion until such a time If necessary, and if the child is >10yrs, remove the entire
as you can get a fibula transplantation done. shaft of the fibula, except for its lower 5cm. Use a Gigli
If a child's tibia is completely destroyed, the fibula may saw, not an osteotome, or bone-cutting forceps, which will
hypertrophy, and push the foot into varus; this needs splinter it. Be very careful to avoid the common peroneal
expert correction. nerve winding round its upper end.

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7.12 Osteomyelitis of the calcaneus & talus THE CALCANEUS

Use the prone position with a support under the foot.

The calcaneus is a completely cancellous bone which Make a longitudinal incision exactly in the middle of the
never forms an involucrum and seldom an isolated heel. Start it in the midline level with the base of the
sequestrum. Pus soon perforates its periosteum without 5th metatarsal. Extend the incision proximally to split the
destroying much of its cortex. The most practical distal end of the Achilles tendon for about 3cm.
operation, and some would say the only one, is to remove Incise the plantar aponeurosis in a plane between the flexor
the whole of the calcaneus to obtain an ugly but digitorum brevis and abductor digiti minimi. Shell out the
surprisingly useful foot. bone. You cannot remove it from inside its periosteum,
so strip this away from the soft tissues of the heel and
remove the bone completely, either as a single piece or in
several smaller ones.
CAUTION! Start in the midline, stay close to bone and
reflect everything you meet medially and laterally. In this
way you will avoid important structures, especially the
plantar nerves entering from the medial side of the foot.

POSTOPERATIVELY, allow the wound edges to collapse

together, but do not suture them. Apply much gauze.
Hold the ankle in a neutral position with a gutter plaster
splint held with a crepe bandage. As the wound heals, start
walking with crutches; later progress to full weight-
bearing. The edges of the scar will turn deeply inwards and
split the heel into two cushions. If its surface is uneven,
suggest wearing shoe pads.

THE TALUS

Presentation is with a painful ankle. Radiographs show an

irregular dense talus. Sequestra are unusual. If you apply a
below knee cast and treat with an antibiotic for 3wks the
infection will probably settle without surgery,
but degenerative arthritis may follow.

7.13 Osteitis of the cranium

Flat bones like those of the skull differ from long ones:
(1);They have little marrow between their diploë, so that
when they are infected the condition is an osteitis, rather
than an osteomyelitis.
(2);Unlike long bones, flat bones seldom sequestrate, and
do not form an involucrum.
(N.B. Osteitis of a rib is usually due to TB).

When sequestra do form in the skull, it is usually because

a burn has destroyed the blood supply to the outer diploë.
Fig. 7-12 OSTEOMYELITIS OF THE CALCANEUS.
Split the heel for the easiest approach to the calcaneus; this brings no
disability. A-B, after the operation. C, expose the calcaneus. Osteitis of the skull presents with headache, combined
D, osteomyelitis of the right calcaneus with a sinus. with tenderness and swelling over the lesion which may be
After Crenshaw AH, Campbell JW Operative Orthopaedics, CV Mosby, particularly marked. It may be secondary to:
5th ed 1971 Fig. 10-18 with kind permission.
(1) A deep burn,
(2) An open skull fracture.
If infection is limited to the pin track, opening up and (3) Frontal sinusitis (29.8).
scraping out the granulation tissue from around the pin
(4) An extradural abscess (6.5).
track may occasionally be all that is needed.
(5) Septic thrombophlebitis of the scalp.
You can approach the calcaneus from either side in order (6) Pyaemia causing metastatic lesions in the skull.
to drain a soft tissue abscess or to remove a window from
the cortex during the acute stage of osteomyelitis.

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When you plan the incision, consider the arteries of the 7.14 Osteomyelitis of the jaws
scalp, and incise between them. For example, do not make
a transverse incision in the temple which will divide the
temporal artery. Split skin grafts will not take on bare Osteomyelitis can affect either of the jaws, usually the
skull, but they will take on granulations. So, if necessary, lower one, and can be secondary to:
remove dead bone, apply saline dressings for a few days, (1);An infected tooth socket in an adult, especially the
and wait for granulations to form. mandible (6.9, 31.3). Suspect it if there is pain, swelling,
CAUTION! (1) If a sequestrum is firmly anchored, use tenderness, trismus, and fever after he has had an infected
an osteotome and light taps from a heavy hammer; tooth removed (sometimes months before), or an alveolar
do not open the dura or injure the brain. abscess drained.
If the osteomyelitis becomes chronic there may be sinuses
If osteitis follows FRONTAL SINUSITIS (29.8). over the lower face, or over the inferior border of the
Define the extent of the frontal sinus with radiographs. mandible (31-9). The offending teeth are usually loose,
Shave the anterior 3cm of the scalp. Make a long incision and you may see pus discharging around them.
above the hairline from ear to ear, and reflect the skin of (2) An open fracture, especially comminuted, of the lower
the forehead downwards as a flap, based on the jaw.
supraorbital vessels. (3) Cancrum oris (31.5).
(4) Sickle-cell disease.
(5) Actinomycosis (31.6)

ACUTE OSTEOMYELITIS

If osteomyelitis is due to an infected tooth, extract the

tooth (31.3).
If it is due to an open fracture or haematogenous, it is
probably subacute and can be satisfactorily treated by
antibiotics.

CHRONIC OSTEOMYELITIS

RADIOGRAPHS. PA and oblique views may rarely show

a sequestrum, or a patchy osteoporosis accompanied by
new bone formation (dense thickened bone).
No significant radiographic changes with multiple skin
sinuses discharging ‘sulphur granules’ suggest
actinomycosis (31.6).

TREATMENT. Treat with antibiotics (cloxacillin or

chloramphenicol) for up to 2wks. Improve the oral
hygiene. Remove any loose teeth. If a sequestrum is
present, remove it. There is no need to wait for an
involucrum to form unless the sequestrum is very large.

SEQUESTRECTOMY

(1) MAXILLA. As the dead bone separates, it loosens.

Wait for nutrition to improve. If the sequestrum is small
and loose, remove it under sedation only. If it is larger,
Fig. 7-13 SEQUESTRUM IN THE SKULL.
There is a dense white sequestrum in the skull, which has extended remove it under ketamine in toto or in pieces. If necessary,
forwards. Burns of the scalp are however the commonest cause of chip away a little living bone. Curette the residual defect.
necrosis of the skull. Another cause is septic thrombophlebitis of the If the cavity bleeds, pack it for 5mins.
scalp, which causes it to necrose and expose the bone underneath.
Kindly contributed by Gerald Hankins
(2) MANDIBLE. To avoid an unsightly scar, incise 1cm
Remove the anterior wall of the frontal sinus; try to curette below the inferior border of the ramus of the mandible.
away all its lining, so that no more fluid will form. Cut through healthy skin and subcutaneous tissue near the
If possible, try to establish drainage through the nose. sequestrum. Avoid, or clamp and tie, the facial artery and
Insert drains through stab incisions above the outer end of vein, as they cross the ramus of the mandible 3cm
each eyebrow. Lead them horizontally from the frontal (in an adult) anterior to its angle. Chisel away the outer
region of the sinus through these incisions. Or, insert them bone covering the sequestrum and curette the cavity.
below the inner eyebrows. Close the flap. Close the wound loosely, leaving a corrugated drain
through one end, or through a separate stab wound.

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CAUTION! Do not operate on a malnourished child 7.16 Septic arthritis

until the general condition is acceptable.
An infected joint is another condition in which failure to
drain pus early is a real disaster: severe chronic and
7.15 Osteitis of the spine, pelvis & ribs probably painful disability results. If you do not drain the
infected joint early, it will be destroyed and may
The spine can rarely be affected by suppurative osteitis: ultimately ankylose. In a child, the epiphyses near it may
displace, or dislocate. As soon as you have made the
the patient is usually a very ill child with fever and severe
diagnosis, drainage is urgent: this is not an operation to
back pain, usually in the lumbar region. There may be
leave until the next day! If you allow pus to accumulate
some inflammatory oedema over the spine, which is very
under pressure in the hip, it may impair the blood supply
tender, and may be arched backwards by muscle spasm, as
if he had tetanus or meningitis. to the head of the femur within 8hrs, so that it necroses.
Ultrasound (38.2G) or radiographs may show a Pus can also damage a joint, even if the blood supply is not
impaired.
paravertebral abscess, usually with normal bones.
There may be paraplegia as the result of inflammatory
Bacteria can reach a joint:
oedema involving the cord. If there is to be any chance of
(1).Before the age of 6 months from osteomyelitis in the
survival the pus must be drained by removing the
transverse processes of some of the vertebrae and part of metaphyses of any long bone. After this age the epiphyseal
some of the ribs. If there are no spasms, recovery will plates prevent spread like this.
(2).At any age in the hip, because the proximal metaphysis
probably occur in 3-6 months. But if there are extensor, or
of the femur is partly within the capsule of the hip joint.
worse, flexor spasms, the paraplegia is likely to be
This makes septic arthritis of the hip and osteomyelitis of
permanent.
Osteitis may be chronic in an older child or adult. There is the neck of the femur, virtually the same disease.
pain, but little or no fever, and no arching of the back. The hip may also be infected in a child as a result of
femoral artery or vein puncture.
Tuberculosis of the spine (32.4) is the commonest type of
(3).Through the blood from a distant septic focus,
spondylodiscitis (infection of the disc space). This occurs
or IV injection of drugs. This is haematogenous septic
more commonly in HIV-disease. Ambulatory treatment
arthritis, which involves the knee, hip, shoulder, and ankle
with standard anti-tubercular therapy is effective if patients
can walk: there is no advantage of an initial period of bed in this order of frequency. It is more frequent in HIV
rest, application of a spinal POP jacket, or adding disease.
(4) From sexually acquired infections: gonococcal arthritis
streptomycin to the regime. A costo-transversectomy
affects usually knees and ankles.
(32.5) for the drainage of a cold abscess is only indicated
(5).Through a penetrating wound of a joint, especially of
when neurological signs ensue.
the fingers or knee, particularly after an animal bite, or
In sickle-cell disease, salmonella is frequently the cause,
and staphylococcus less so. The only early radiographic previous surgery especially if a prosthesis has been
sign may be disc-space narrowing; treatment with IV inserted.
antibiotics is necessary for 6wks, associated with spinal
The first sign of septic arthritis is immobility. One of the
immobilization. Drainage is required if there is no
joints, commonly the hip or knee, becomes so painful that
response to antibiotics, neurological signs ensue, or there
moving it even a little in any direction causes great pain.
is an epidural abscess.
Sometimes, several joints are involved at the same time.
There is usually pyrexia. The combination of fever and a
THE SPINE
painful immobile limb is either caused by osteomyelitis,
If there is marked osteoporosis but minimal or no
or septic arthritis, until you have proved otherwise.
osteosclerosis, suspect tuberculosis.
Later, if the infected joint is near the surface, you will be
If the bodies of the vertebrae are abnormal, but not the
intervertebral discs, suspect malignancy. able to feel that it is warm and swollen with fluid.
Unfortunately, the shoulder and the hip are so deep that
If the disc and the adjoining bone are diseased,
you cannot easily detect fluid, so that the only local sign is
especially if this is maximal anteriorly, suspect infection.
acutely painful limitation of movement.
The diseased bone softens, and the vertebral bodies
become wedge-shaped.
Septic arthritis does not always run a typical course,
In a child, consider Burkitt’s lymphoma (17.6).
and so is not often easy to diagnose. Here are some of the
THE PELVIS. difficulties:
(1).In the very old or very young, there may be few
Osteitis of the pubis may occasionally follow
general signs of infection, and the effusion may not even
symphysiotomy (21.7).
appear to be inflammatory.
If it involves the innominate bone, try antibiotics for up to
(2).In the spine, the sacroiliac joints, and the hips,
6wks. Sequestra are unusual.
pain may be the only presenting symptom.
THE RIBS. (3).The pus may be too thick to aspirate.
(4).Only 50% of patients have a fever or a leucocytosis,
Osteitis of the ribs is rare, and almost always due to
especially if HIV+ve.
tuberculosis, usually only confirmed on rib resection.

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(5).You can easily confuse tuberculous with subacute Congenital syphilis presents as swelling of both knees
suppurative arthritis. To distinguish them, rely on the without much fever, in childhood.
radiograph and your findings on aspiration (pus or caseous Actinomycosis and mycetoma (34.11) may also invade
tissue). joints from outside.
If you are still in doubt, treat for both diseases. Review the
progress at 3 & 6wks, when suppurative arthritis should Several things can happen to a severely damaged joint:
show much improvement, whereas it is still too early for (1) It can dislocate.
tuberculosis to show much change. (2);An epiphysis can slip, either immediately, or several
weeks later (7-14).
(3);It can become fixed in a painless stable bony ankylosis
in the position of function.
(4);It can develop a painful unstable fibrous ankylosis,
which can be a serious disability.

HASINA (17yrs) was admitted with pain in her left hip and inability to
walk for 3 days. She was given physiotherapy, nursed on a fracture bed
for 3wks, and discharged on crutches. Some weeks later she was
readmitted, pyrexial, and with a swelling of her right thigh extending
from her knee to her iliac crest. 3l yellow-green pus were aspirated
(7-14).
MARIAMU (12yrs) was admitted with osteomyelitis of her tibia.
This was settling nicely when she developed pain in her left hip and
became pyrexial. The radiographs of her hip were normal, septic arthritis
was diagnosed, and she was given large doses of the latest
broad-spectrum antibiotic. Her pain improved slowly but her fever
continued. Later, radiographs showed destruction of the head of her
femur. Traction was applied. Sinuses developed, and she was never
able to walk again. Two years later her pain was so severe that she had to
have her hip disarticulated. All this happened in a 'good' hospital.
LESSONS (1) The early diagnosis of septic arthritis of Hasina's hip was
not made, although the history and signs were obvious. (2) Rest in bed on
traction would have prevented her epiphysis slipping. At best she will
have a painful hip, either for life, or until her hip has ankylosed
spontaneously, or been fused surgically.(3) Explore a hip on the suspicion
of septic arthritis.

ASPIRATE ALL SPONTANEOUS JOINT

EFFUSIONS DRAIN ALL INFECTED JOINTS

ASPIRATION. Use pethidine IV; thoroughly sterilize the

skin site you plan to use for the aspiration. Carefully
Fig. 7-14 DISASTER WITH AN INFECTED HIP. choose the site of puncture and push a large (1·2mm)
Radiograph and classic position seated. Infection has displaced the
needle down into the joint (7-15). The critical investigation
epiphysis of the femur, and moved its shaft upwards. The infection in
the thigh is producing gas. is to aspirate the joint as soon as you suspect infection.
Frank pus in the syringe, or even slightly cloudy synovial
The diagnosis is particularly difficult in babies: fluid, confirms the diagnosis. You may get a false
negative, but apart from contaminants in the culture, you
AHMED (1yr) was brought by the mother saying he had fever and was will never get a false +ve result. Aspiration alone is not
drawing up the left hip in pain. This in itself was unusual, because,
if a baby does this, he usually draws up both of them. He was found to
enough; it only tells you that pus is present: you must
have suppurative arthritis of the right hip, which was too painful to move. thoroughly irrigate the joint till the effluent is clear.
It was aspirated, antibiotics were started within 24hrs, and he recovered. However, aim to aspirate as much of the pus as you can.
LESSON The diagnosis was made early and treatment started Aspirating the more superficial joints is usually easy
immediately. (7.17).

Septic arthritis is more common in the disadvantaged and If you fail to aspirate a joint that you think is infected,
malnourished and also in infancy and old age. you must incise and drain it, i.e. perform an arthrotomy.
It is common in HIV disease, as well as diabetes mellitus, The results of not doing so are so serious, that the dangers
chronic renal failure and in joints previously damaged by of attempting it are well worthwhile. Likewise, if the pus
trauma or inflammatory disease. is too thick to aspirate properly, perform an arthrotomy to
Staphylococcus aureus is the dominant organism, but if the wash out the joint.
patient has HIV or sickle-cell disease, you may find E. coli
or salmonella in the joint. Haemophilus influenzae is the SPECIAL TESTS. Culture the synovial fluid (30% +ve
most frequent organism in newborns, but is seldom seen in result) and blood (14%). Screen for HIV.
older patients.
Other organisms include streptococci, brucellae,
and gonococci.

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RADIOGRAPHS. Signs are:

(1) Widening of the joint space.
(2) The signs of early osteitis (7.3). You may see the first
signs of new bone formation as early as the 5 th day in an
infant, but it will not appear before the 10 th day in an older
child, and may take longer.

ANTIBIOTICS. Try to isolate the organism, otherwise

cloxacillin or chloramphenicol are most suitable.
Under 5yrs, salmonella is most common. In acute cases
treat for 2-3wks; in chronic cases for up to 6wks.
When infection is well established, antibiotics seldom
help. Treated early, septic arthritis may recover fully.

If, when you drain an infected joint and wash out the
pus, its joint surfaces are smooth, there is a good chance
of having a normal or nearly normal joint. The prognosis is
worse if cartilage has been lost, if the joint surfaces are
rough, if the bone is soft, or if the radiograph shows severe
joint destruction. Even so, there is still some hope of a
movable joint, especially in the young; a child's epiphysis
may appear to be largely destroyed on a radiograph, and
yet regenerate considerably.

EXPLORATION ARTHROTOMY. (GRADE 2.1)

Open the infected joint. Use a tourniquet where possible,
and if the hand is involved, watch out for its nerves.
Irrigate the interior of the joint forcefully using a syringe
and warm water. Do this until the fluid comes back clear.
Feel the surfaces of the joint. Leave the wound open.
The linear incision you have just made will become
elliptical, and you will see the cartilage underneath.
If the joint is superficial, it needs no drain. If it is deep,
as in the hip and shoulder, insert a rubber drain.

If the joint surfaces feel smooth, the prognosis is good.

After 10days of rest start gradual active movements.

If the joint surfaces feel rough but some cartilage still

covers the bones, there may still be useful function in the
joint.

If all its cartilage has been destroyed, the prognosis is

bad. The best hope is a stable ankylosis in the
position of function (7-16). If the hip or knee are involved, Fig. 7-15 ASPIRATING A JOINT may confirm the diagnosis, if pus
apply temporary skin traction. is thin enough to come out of the needle. It is not effective treatment
alone unless you wash the joint thoroughly.
If, later, there is a persistently painful joint with A, wrist. B, elbow. C, posterior approach to the hip. D, anterior
approach to the hip. E, knee. F, ankle. G, posterior & H, anterior
limited movement, an arthrodesis is indicated. Fusing a approaches to the shoulder (right sided joints shown).
joint is difficult in a child, and is rarely necessary; A-F, after Dudley, HAF (ed) Hamilton Bailey's Emergency Surgery.
if it is done too early, there will be growth problems so Wright 11th ed 1986, with kind permission. G kindly contributed by Jack
delay this as long as possible. Lange.

The position of function is the best position for a joint to

be in if it is going to be fixed, or if its movement is going
7.17 Methods & positions for septic joints to be severely limited. It is also called the position for
(except the hip) ankylosis

Joints need to be in particular positions for particular The position of rest is the most comfortable position for a
purposes, so be sure to get it right. These positions seldom joint to lie. Put it into this position if it has to be rested for
coincide with one another, and the position of function is any reason, but is in no danger of ankylosing.
absolutely critical.

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The neutral position of a joint is that from which its THE POSITION OF A JOINT IS ALL IMPORTANT!
movement is measured. It is for anatomical description
only. A. THE SHOULDER

The position of safety is for the hand only. It is the ASPIRATION

position in which the collateral ligaments of the finger Posterior route: sit the patient in a chair to face its back,
joints are stretched, and in which fingers which are ask him to touch the opposite shoulder with the arm that is
temporarily not going to be moved are least likely to to be aspirated, so as to adduct and internally rotate the
become stiff. shoulder. Feel for the head of the humerus. Keeping the
Any kind of ankylosis, stable or unstable, is a dreadful needle horizontal, push it 30º medially into the joint space,
disability if the joint becomes fixed in the wrong position, from a point just under the postero-inferior border of the
so make sure that, if it is going to ankylose, it does so in acromion (7-15G).
the most useful position. The position of function varies Anterior route: this is easier but more hazardous.
from joint to joint, and may depend on what the patient Feel for the coracoid process just below the clavicle in the
wants to do with it. You never know for sure when a joint space between the pectoralis major and deltoid muscle.
is going to ankylose, so put it into the position of function Push the needle into the joint slightly below and medial to
for every case of septic arthritis. For example, splint the the tip of the coracoid process. Slope it laterally 30º and
knee just short of full extension; splint the right push it backwards, until it enters the loose pouch under the
(or dominant) elbow flexed. Make quite sure this position lower part of the shoulder joint (7-15H).
is maintained before discharge! Do not leave this task to a
physiotherapist in the hope that it will be achieved later! EXPLORATION ARTHROTOMY. (GRADE 2.4)
Approach the shoulder joint as if you were operating on
the upper humerus for osteomyelitis (7-7), and separate the
deltoid from the pectoralis major in the deltopectoral
groove. Open the joint and irrigate with warm sterile
water. Keep the wound open with a drain into the joint.

POSITION OF REST. Put the arm in a sling.

POSITION OF FUNCTION.
Put the shoulder into a spica in 45º of abduction, with the
elbow just anterior to the coronal plane, in 70º of medial
rotation so that the hand can reach the mouth.

B. THE ELBOW

ASPIRATION.
Bend the elbow to 90º. Feel for the head of the radius,
the olecranon and the lateral epicondyle of the humerus.
Using these points of a triangle, push the needle through
its centre into the posterolateral aspect of the joint.

EXPLORATION ARTHROTOMY. (GRADE 2.4)

Make a 3cm longitudinal incision posteriorly in the sulcus
between the olecranon and the head of the radius.
Go through the skin and fascia, insert a haemostat, and
open the joint. Irrigate it with warm sterile water.
Keep the joint open with a drain.
CAUTION! Stay close to the olecranon, and remember
that the posterior interosseous nerve winds round the neck
of the radius 3cm distal to its head.
Fig. 7-16 POSITIONS OF FUNCTION
If a joint is going to ankylose, the position in which it does so is POSITION OF REST.
critical. A, notice that the shoulder is abducted, the right elbow is Keep the arm in a sling in 90º of flexion.
flexed and in mid-pronation, the left elbow is extended (for toilet
purposes) and B, the knee is just short of full extension, and the ankle
is in neutral and slightly everted. C, this girl had an infected burn of POSITIONS OF FUNCTION depend on whether one,
her right elbow. The joint became infected. Tragically, it was allowed or both joints, are going to ankylose.
to ankylose in nearly full extension, so that she cannot eat with it or
write! Kindly contributed by John Stewart.

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If the dominant elbow is going to ankylose, consider the EXPLORATION ARTHROTOMY. (GRADE 2.4)
patient’s needs. For example, Muslims and many other With the knee extended, make a 5cm incision 2cm behind
peoples write and eat with their right hands and use their the medial edge of the patella and its tendon. Go through
left hands for toilet purposes. If so, the right elbow should the quadriceps expansion, longitudinally, and put a curved
be more flexed than the left. The dominant elbow will haemostat into the suprapatellar pouch, under the surface
probably be most useful if it is flexed 10º beyond a right of the patella. Put your finger into the joint and use it to
angle, with the forearm pronated 45º so that feeding, remove the pus. Take a piece of joint capsule for biopsy.
scratching the nose, and writing are possible. Put it into Irrigate the joint with warm sterile water. Leave the wound
this position by fitting a collar and cuff. open, or sew up the upper part, and leave a corrugated
drain in place. Dress the wound and apply skin traction,
If both the elbows are going to ankylose, arrange their or a plaster backslab. Without one or other a painful
positions so that the dominant arm can reach the mouth. flexion contracture is likely. Leave the drain in for
Let the non-dominant elbow fuse in 10º short of full 4-7days.
extension, so the hand can reach the anus.
POSITION OF REST.
C. THE WRIST Apply skin traction to the lower leg to prevent flexion.
Or apply a plaster backslab held on with a crepe bandage.
ASPIRATION.
Feel for the radial styloid; it will show you the line of the If there is already a flexion contracture following septic
joint. Feel for the tendons of extensor pollicis longus on arthritis, put the knee in extension traction until it has
the radial side of the 'anatomical snuffbox'. Aspirate on its been corrected. Then apply a cylindrical cast and
ulnar aspect, at the level of the wrist joint. Push the needle encourage weight-bearing. With luck, a painless bony
between extensor pollicis longus and the index tendon of ankylosis will develop. If this does not happen,
extensor digitorum into the joint inclining it proximally a compression arthrodesis of the knee will be necessary.
45º (7-15A).
POSITION OF FUNCTION.
EXPLORATION ARTHROTOMY. (GRADE 2.4) Make sure the knee ankyloses in 10º of flexion, so the foot
Flex and extend the wrist, as you feel for the exact line of can just clear the ground on walking. Do the same when
the joint. Feel for the hollow between the tendons of both knees are ankylosed.
extensor pollicis longus and the index tendon of extensor
digitorum. Make a 3cm transverse incision, taking care not F. THE ANKLE
to cut the cutaneous branch of the radial nerve which runs
in the web space of the thumb. Retract the skin edges and ASPIRATION.
expose the joint through a longitudinal incision between Find the line of the joint by moving the ankle. Insert the
the two tendons. Irrigate the joint with warm sterile water. needle into its anterior aspect just medial to the lateral
malleolus. Push it backwards and slightly downwards,
POSITIONS OF REST AND FUNCTION. so that it enters the space in the angle between the tibia
Keep the wrist in 30º of extension with a volar plaster slab. and the talus.

D. THE HAND EXPLORATION ARTHROTOMY. (GRADE 2.4)

Start the incision on the anterolateral aspect of the ankle,
THE POSITION OF SAFETY is peculiar to the hand and 5cm above the joint, and continue it downwards 1cm in
is the position which will minimize stiffness after an front of the lateral malleolus to the base of the
injury. Keep the mcp joints nearly fully flexed, the pip and 4th metatarsal, lateral to the extensor tendons of the toes.
dip joints fully extended. Keep the thumb well forward of Divide the superior and inferior extensor retinaculum as
the palm in opposition to the fingers, with its pulp about far as is necessary, so as to expose the capsule of the ankle
4cm from them. To maintain this position use aluminium joint. Then divide this and open the joint. (This incision
finger splints, plaster slabs, or a boxing glove dressing, as will expose both the ankle and the tarsal joints).
appropriate.
POSITION OF REST.
E. THE KNEE. Keep the ankle in neutral, without any flexion, extension,
inversion, or eversion. Apply a plaster gutter splint.
ASPIRATION.
Extend the knee. Push the needle into the suprapatellar POSITION OF FUNCTION.
pouch 2½cm above the upper border of the patella, from Keep the ankle neutral and slightly everted. Inversion will
either the medial or the lateral side. produce painful callus under the head of the 5th metatarsal
on walking.

ANKYLOSIS IN THE WRONG POSITION

IS A REAL DISASTER!

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7.18 Septic arthritis of the hip Bend the knee to 90º and then flex the hip (7-17B).
If the leg turns to external rotation as you do this, the head
of the femur may have slipped. Confirm this by taking a
An acutely tender hip in varying degrees of flexion, ‘frog-leg view’ radiograph. If a sequestrum has formed,
together with fever, suggests infection. An important sign open the hip joint and remove it.
is spasm of the hip muscles. Test for this by rolling the (3);The hip joint may be destroyed. When this happens,
thigh (7-17). If this is acutely painful, suspect that the hip there are 2 choices:
is infected. If there is septic arthritis or osteomyelitis (a) Fuse the hip in the position of function by applying a
tapping the greater trochanter lightly with your clenched spica for 3 months or more.
fist will be painful; if there is deep inguinal adenitis (6.16) (b) Remove the remains of the partly destroyed head and
or pyomyositis (7.1), it will not. In septic arthritis or neck of the femur by Girdlestone's operation (7.19).
osteomyelitis the epiphysis of the femur may become This will result in a much more comfortable joint with
indistinct, or even absent on a radiograph, but it often some movement.
reappears. This is not an indication for its removal! (4);The infection may extend into the acetabulum and
involve the bones of the pelvis. When this has happened,
there is little you can do, except drain the pus. The osteitis
usually settles.

Fig. 7-17 SIGNS IN SEPTIC ARTHRITIS OF THE HIP.

A, lie the patient flat, place your hand on the thighs and try to roll
the leg to and fro. A normal hip rolls easily; if it is infected, this will
be acutely painful. B, if you flex a normal hip, it will flex without
rotation. If it rotates externally into position 'X' as you flex it, the
upper femoral epiphysis may have slipped. This can happen
spontaneously in teenagers; it also happens in late septic arthritis.
Kindly contributed by John Stewart.

There are 3 operations you may need to perform, but only

the 1st is common. Be prepared to:
(1) Drain pus in septic arthritis.
(2);Remove the head of the femur, when this has been
destroyed as the result of infection.
(3);Perform Girdlestone's operation in chronic septic
arthritis to remove the head and neck of the femur (7.19).
Sepsis may also follow after an arthroplasty or hemi-
arthroplasty. Draining the pus in these cases is just as
important; removing the prosthesis is difficult and may not
be necessary: it is anyway something for an expert!

If you do not treat septic arthritis of the hip early,

any of these things may happen:
(1);A flexion contracture may develop, which will be a
great disability, if you let it become permanent.
Prevent and treat this in 2 ways.
(a);Apply extension (skin) traction to the lower leg.
This is very effective prevention, so do it routinely.
(b);If a contracture has started to develop, extend the leg
by using the prone position if this is tolerated.
Fig. 7-18 ANTERIOR APPROACH TO THE HIP.
Few patients, especially children, will do this for long if A, incision. B, retract the muscles. C, prepare to incise the capsule.
their bed faces a wall! So make sure the bed faces the (1) anterior superior iliac spine. (2) pubic tubercle. (3) femoral vein,
centre of the ward. artery and nerve from medial to lateral in this order. (4) sartorius.
(2);The upper femoral epiphysis may slip off the shaft of (5) rectus femoris. (6) ascending branch of the lateral circummflex
vessels. (7) exposed surface of the ilium. (8) gluteus medius and tensor
the femur, and become a dead sequestrum in the hip joint fascia lata. (9) incision in the capsule.
(7-14). Later in the course of the disease there is a useful
test to find out if it is slipping.

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ASPIRATION POSTOPERATIVELY, apply 2-5kg of skin traction up to

The hip lies immediately behind the mid inguinal point. the mid thigh, with the leg in 1-15º of abduction and
Use a thick lumbar puncture needle. If you can, do this minimal flexion. Raise the foot of the bed.
under ultrasound guidance. If the anterior approach fails,
try the posterior one.
Anteriorly, feel for the femoral artery 2½cm below the
inguinal ligament midway between the anterior iliac spine
and the pubic tubercle. Insert the needle 1½cm lateral to
the artery (and thus lateral to the femoral nerve).
If you cannot feel the femoral artery, insert the needle
2½cm below and 2½cm lateral to the mid-inguinal point.
Push the needle in, inc