SKID ROW presents DAVID A. LINDSTROM, M.D. A MEDICAL CORPORATION 1229 SOUTHEAST TOWER 45 LINCOLN DRIVE LOS ANGELES, CALIFORNIA 90024 MEMO DT: 9/10/88 TO: All First-Year Residents FM: Dr. David Lindstrom, Chief of Surgery RE: Welcome As Chief of Surgery, I would like to extend my heartfelt welcome to each of you. While you are probably anxious to begin your duties, please take a moment to examine the orientation materials enclosed. 1. The "New Resident Orientation" (rev. 9/88) handout (attached to this memo), detailing basic hospital procedures of patient admittance, diagnosis and the use of message papers. 2. The Life & Death Operating Procedures and Reference manual, explaining how to get started, with a copy of chapters IV, V and Appendix A of Merl and Newman's classic text "Anatomy and the Surgical Technique" (Copyright 1938, 1956, 1987, reprinted with permission of STW Medical Press). While our medical center is a general admitting facility, we take special pride in our Department of Abdominal Surgery, founded in 1943 by Drs. Robert Merl and Simon Newman. Due to our expertise, many patients with abdominal complaints are transferred to TGH and - even as a resident - you can expect to see many such cases. This reprint should help refresh your memory regarding the techniques and terminology of abdominal surgery. 3. A history of surgery. It has long been the belief of the hospital Board of Directors that modern medical instruction, with its emphasis on technique, neglects the more human aspects of the healing arts. This document is intended, in small measure, to correct this oversight. During the day, you can often find me in the classroom where I give daily lectures. I will be more than happy to respond to any problems you may be having with diagnosis or surgical techniques. Once again, welcome to Toolworks General. Toolworks General Hospital New Resident Orientation (Rev. 9/88) Welcome to Toolworks General ---------------------------- We know that the first few days as a surgical resident can be difficult, so we have put together this orientation handout. Use it to familiarize yourself with the layout of TGH and the procedures you will be expected to follow. Refer to the "Operating Procedures Manual" (enclosed) in any instances that you feel more specific instructions are required. Good luck! Your Responsibilities --------------------- You will be working on the eight floor, under the auspices of the Department of Abdominal Surgery. This is a separate unit with its own personnel staffing, record keeping and teaching facilities. As you know, your job is to diagnose patients (after ordering any necessary tests), prescribe treatments or drugs and - when appropriate - operate. In short, you have all the privileges and responsibilities of any other surgeon in the hospital. About the only difference is that Dr. Lindstrom will be tracking your progress and offering guidance when needed. Upon Arrival ------------ When you arrive at the start of your shift, the first thing you should do is check in at the Nurse's Station. Hospital policy requires that all residents sign in before cases will be assigned. Monica Pierce, the Charge Nurse, keeps track of the sign-in list. Once you sign in with Monica, she will make sure you will receive any messages and let you know if you have patients waiting. Hospital Paging System ---------------------- The Board of Directors has installed, at great expense, a hospital message paging system. The paging system assures that all physicians can be located immediately so that test results, medical histories and other critical information can be passed to you quickly and efficiently. All physicians (except when in surgery) are required to carry their beepers and to respond as soon as possible to a page. Failure to respond in a timely manner will result in dismissal from the staff and termination of your hospital privileges. When your beeper goes off, return as soon as possible to the Nurse's Station. Nurse Pierce will relay the message and make a phone available so you can return the call. If you are uncertain how to operate your beeper, please see the more detailed instructions located in your "Operating Procedure Manual," also found in this information packet. The Floor Plan -------------- Aside from the Nurse's Station, there are several other areas with which you should become familiar. Across the hall from the Nurse's Station is the Classroom, where Dr. Lindstrom holds daily lectures (along with special sessions for residents needing extra instruction.) The Classroom is fully equipped for audio-visual presentations and will become an integral part of your continuing education in abdominal surgery. Patient Rooms ------------- The numbered doors at the end of the hall lead to patient's rooms. While on duty, you are the attending physician for all patients on the floor. It is your responsibility to look in on the patients and check their progress. An up-to-date medical history for each patient may be found on the clipboard at the base of the patient's bed. If you feel additional test, medication or surgical prep is indicated, mark the appropriate action on the clipboard. See the "Operating Procedures Manual" for more specific instructions on surgery as well as ordering medication and tests. The Personnel Office -------------------- Shelly Marks administers the personnel office. We recommend that you visit Shelly to select your surgical team. You will find that, while each staff member is skilled and competent, all have slightly different educational backgrounds, experience and personalities. It may take a while to discover the combination of talent and personality with which you feel most comfortable while in the operating theatre. The Operating Theatre --------------------- The double doors to the left of the Nurse's Station lead to the Operating Theatre. After surgical prep is ordered, the patient will be brought to the OR when ready. ------------------------------------------------------------------------------ SKID ROW presents LIFE & DEATH OPERATING PROCEDURES MANUAL & DIAGNOSTIC and TREATMENT METHODS Page 2 \/ LIFE AND DEATH OPERATING PROCEDURES MANUAL FOR THE COMMODORE AMIGA Life & Death is a game for fun, not education. Nothing that appears in or on the package, manual or the software program is in any way intended to be a statement or representation of fact or medical opinion applicable to any situation other than the playing of the computer game. No representation or warranty is made that any statement, diagram or image is accurate as a fact or valid as an opinion concerning any anatomical, medical, surgical or health matter. UNDER NO CIRCUMSTANCES should any person rely upon or be influenced by these materials in making any health related decision. You, of course, should consult qualified medical personnel whenever you have any questions or problems concerning health or medical matters. Requirements Life & Death runs on any Commodore Amiga computer with at least 512K of memory. If you are running a 512K Amiga, you should turn off any external drives before running this game. A mouse is required. Definition of terms Throughout this manual terminology native to mouse devices will be used. The cursor marks a location on the screen with a pointer arrow. The cursor location can be changed by sliding the mouse. The location of the cursor represents the area where you may begin an action. Once the cursor has been moved into position, the left mouse button is used to activate an object or begin a process. Press and release the mouse button, while the cursor is over the object you wish to activate. This procedure is called clicking. Dragging is much like clicking. While over an object press the left mouse button but do not release it. Instead, move the cursor to a new position on the screen Moving the cursor with the button pressed is called dragging.. During the operation, the cursor will be represented by a small hand. This miniature image is called an icon.. The small hand icon symbolizes an empty hand. The icon can be changed by clicking on an item. If, for example, you were to move the hand icon over the image of the scalpel and press the button, the cursor icon would change from the hand to the scalpel symbolizing grasping the scalpel. If you click the cursor on an empty area of the tray, while you have the scalpel in your hand, the cursor will change to your hand, symbolizing dropping the scalpel. Moving around the hospital To move around the hospital, use your mouse. To enter or leave a room, click on the door. To pick up a clipboard, click on it. To put a clipboard down, move the Page 3 \/ mouse icon off the clipboard and click. While viewing lessons in the classroom, click on the chalkboard to ask the instructor to put up the next lesson. To leave the hospital, exit through the doors at the far end of the hall. Feel free to explore all of the rooms and objects at Toolworks General Hospital. When clicking, always use the tip (upper left) of the mouse arrow to indicate where you want to go or what you want to pick up. The arrow will turn into an hour glass when the program is busy. Signing in Before you can be assigned any patients, you must inform the hospital staff that you have arrived. Nurse Pierce will offer you the sign-in clipboard in the main hall. Click on the clipboard and you will be presented with a sign-in sheet. If you are a returning doctor, just click on your name. Once you have signed in, the program will remember everything about you, even if you leave the hospital and come back to play another time. Diagnosing a patient To diagnose a patient, you should first read the patient's reported symptoms. These symptoms can be found on the clipboard at the foot of the patient's bed. Click on the clipboard to pick it up. To put the clipboard down, move the icon off the clipboard and click. To preform a physical examination of the patient, click on the patient's body. You will be presented with a close-up of the torso. To palpate a particular region, move the mouse to the area and click. Note the patient's responses. To end a physical examination click on the bed covers. The patient's clipboard is also used to order a particular treatment or more tests. Use your mouse to put a check mark in the appropriate box. You must put your initials in the space provided in order for the staff to carry out your request. Remember to put the clipboard down when you have finished with it. Medical school Whenever the chief of surgery feels that you need schooling, you will be instructed to report to the medical school. Most of the lessons in medical school are written on the chalkboard. The classroom is also outfitted with audio-visual equipment that will sometimes be used after an unsuccessful surgery. Page 4 \/ Answering a page When Nurse Pierce gives you a message that someone has called, it is in your best interest to return the call. Use the beeper that came with your Life and Death package to determine the number where they can be reached. Line up the person's name (eg. Morgan) and where they called from (eg. Pathology) in the top beeper window. The correct phone number is contained in the window corresponding to the phone line used for the call. Pick up the phone on the main desk and dial this number. When dialing the phone, you may push the phone buttons by clicking the mouse button over the phone number image. Surgery When you first start surgery, the mouse icon will be in the shape of a hand. Click on an instrument to pick it up. Use the tip of the finger to point to what you want to pick up. The icon will change to a representation of the instrument you are currently holding. To put an instrument down, click anywhere on the operating tray. To use an instrument, move the icon to the appropriate place and click. For some instruments, such as the scalpel, sponge, suction and antiseptic, you must click and drag the mouse to use them properly. To open a drawer, first put down any instrument you might be holding and click on the drawer handle. Use the same procedure to close the drawer. When removing forceps from the patient's body, line up the hand with the forceps handle. To retract a tissue layer, pick up the retractor and click near the incision. To close a tissue layer, click on the right mouse button on the layer to be closed. While in surgery, the following keys are active: S: Turns sound on and off. P: Pauses the game. To resume the game, press any key. Hospital Policies and Guidelines The Hospital Policies and Guidelines clipboard is used to set the Life & Death game parameters. To have this clipboard handed to you, click on any intercom. To select or unselect an option on the Policies clipboard, place a check mark (or remove the check mark) in the appropriate box by clicking with the mouse. "Quiet hours in effect" means that the sound will be turned off while playing the game. "Patients may speak" means that the digitized patients' voices will be turned on. Patients may not speak while quiet hours are in effect. There are three play levels available: Novice, Intermediate and Advanced. If you have not yet signed in, the bottom of the Policies clipboard will contain an option called "Remove surgeon from sign up". To remove a doctors name from the sign-up list, choose this option. The program will display the sign-up Page 5 \/ clipboard, at which time you may choose a surgeon to remove by clicking his or her name. Before the name is actually deleted, you will be asked to confirm the surgeon's removal by clicking the appropriate box. NOTE: Each new surgeon starts at the novice level. If you would like a more challenging game, choose the intermediate or advanced play level. At the more difficult levels, you will encounter bleeders and abnormal EKG patterns more often. The comments by the staff members will be less helpful. Also, you will need to be more precise in placing clamps, using the cauterizer and making incisions. For those surgeons who desire a challenge of nightmarish proportions, "Nightmare Mode" is available. Click the appropriate box. Page 6 \/ DIAGNOSTIC and TREATMENT METHODS FROM THE DESK OF: DR DAVID LINDSTROM Page 7 \/ We have found that diagnostic and treatment methods among first year residences sometimes differ. To ensure that everyone here at Toolworks General works under the same guidelines, we have included the following excerpt from "Anatomy and the Surgical Technique," by Drs. Robert Merl and Simon Newman (copyright 1938, 1956, 1987, reprinted with permission of STW medical press). Table of contents Chapter Four - Some Pathology and Treatment 8 Chapter Five - Basic Surgical Techniques and the Abdominal Area 11 Appendix 16 Page 8 \/ Chapter Four: Some Pathology and Treatment Appendicitis Indications: Appendicitis is the infection and inflammation of the vermiform appendix, a superfluous, finger-sized appendage to the cecum at the junction of the small and large intestine. Appendicitis can be marked by any combination of loss-of-appetite, nausea, vomiting, diarrhoea, high fever and acute abdominal pain. Treatment Surgery is indicated in cases of appendicitis. Bacterial Infection Indications: Bacterial infection is the assault upon the body by a bacteria or germ. As the body's defenses attempt to expel the bacteria, certain symptoms manifest themselves. These can include abdominal discomfort, vomiting, diarrhoea, high fever and runny nose. Treatment: Bed rest and medication are required. Intestinal Gas Indication: Symptoms include abdominal pain, generalized weakness and dizziness. Treatment: Observation and bed rest. Kidney Stones Indications: Small precipitates composed of mineral salts extracted from urine sometimes become lodged in the ducts of the kidneys. These renal calculi can cause extreme discomfort in the lower back and flank area. The stones, while rarely fatal, are extremely painful and should be treated immediately. Kidney stones will appear on an X-ray as small dots above the pelvis. Treatment: Kidney-stone patients should be referred to a urologist. Aneurysms Indications: When a blood vessel wall becomes diseased or begins to weaken, the blood vessel begins to dilate (stretch), forming what is known as an aneurysm. Should the artery walls become rough from deterioration, the blood within may clot and form an embolism, further stretching the aneurysm. If the aneurysm occurs in a large artery, the potential bursting of the artery is life-threatening. A particularly dangerous aneurysm occurs in the aorta, the main blood-carrying artery. Aneurysms of the descending, or abdominal, aorta can often be felt as a pulsating mass in the abdomen. The most common symptom is abdominal pain. Ultrasonic scans reveal aneurysms as solid white lumps. Treatment: If an aneurysm swells to a dangerous level, 5 to 6 cm in diameter, the blood vessel's wall must be supported with a dacron graft. Since aneurysms commonly occur in older patients who have less stable systems, surgeons must take care to avoid needless surgery. Page 9 \/ Arthritis Indications: Arthritis is the erosion of joints and their surrounding tissues. Arthritis is often found among older patients and can be extremely painful. Treatment: Arthritis is very difficult to treat. The most successful treatments include cautious exercise and pain-relief medication. Diagnosis Definition: Diagnosis is the study of symptoms in an effort to discover the ailment caused a patient's discomfort. This process involves gathering as much information as possible about the patient and his or her symptoms before proceeding with treatment. Some of the tools found to me most useful are the patient's own report of symptoms, the abdominal exam, the X-ray and the ultrasonic scan. Patient's Reported Symptoms: Symptoms reported by the patient provide a starting point for diagnosis. These symptoms are often written on a clipboard at the foot of the patient's bed. Abdominal Exam: The abdominal exam is often an extension of the patient's report of symptoms. By palpating the abdomen and listening to the patient, the tending physician can gain a more detailed understanding of the symptoms. To perform an abdominal exam, palpate various locations on the patient's abdomen and note the responses. (For more information on examinations, refer to your Operating Procedures Manual.) X-ray: An X-ray is the image of electromagnetic radiation passed through a body and then captured on film. Before it reaches the film below, the radiation passes through porous material, such as skin and muscle, but is absorbed by solid masses, especially bone. X-rays, therefore, show solid masses such as bone but ignore less dense cartilage. Ultrasonic Scan: An ultrasonic scan is similar to sonar. During an ultrasonic scan, sound waves are focused on a body and scanned by a computer. The recorded wave-forms are translated into images of the masses off of which the sound bounced. Ultrasonic scans show the more porous cartilage that is ignored by X-rays. In Conclusion: After the initial evaluation, the physician uses the clipboard at the foot of the patient's bed to request treatment or additional diagnostic options. A hospital staff is not allowed to carry out a physician's requests that do not include his or her initials. Surgery Orientation: Before a surgeon enters the operating room, he or she must consider the following aspects of surgical procedure: First, he or she must be mentally prepared to finish the operation once it has begun. A mental checklist of the steps involved is often used as preparation. Second, the surgeon must constantly monitor the patient's vital signs. Even though the surgical team will help, the Page 10 \/ main responsibility for the patient's well-being is that of the surgeon in charge. Third, every surgeon must be very familiar with the medical instruments he or she must utilize. Vital Signs Introduction: Several devices constantly report the patient's vital statistics during an operation. The electrocardiogram (EKG), clock and blood pressure gauge display the primary information. The IV bottle and anaesthetic dial display secondary information. The EKG: The EKG is an electronic representation of a heartbeat and is used to monitor abnormalities in heart operation. Conditions for which surgeons must be on the alert are Premature Ventricular Contraction (PVC) and Bradycardia. PVC: PVC is thought to arise from an imbalance in the electrical system of the heart and is characterized by a drop in the EKG line. If not medicated, PVC may lead to Ventricular Fibrillation, Characterized by a rapidly modulating EKG line, absent of normal heart rhythm. This condition is usually fatal. Bradycardia: Bradycardia occurs when the heart becomes weak or tired and slows or skips beats. If proper medication is administered , the normal heart rhythm is usually restored. If not, the can lose strength and stop beating. Blood Pressure: The blood pressure gauge describes the measure of pressure the heart exerts on the blood vessel walls as it pushes blood against them. It is expressed in two numbers, the systolic pressure and the diastolic pressure. The systolic pressure, the peak level, measures the maximum pressure of the blood exerted against the vessel walls as the heart contracts. The diastolic pressure represents the force of blood exerted against the walls as the heart relaxes. Blood pressure can drop from prolonged anesthesia or blood loss. Surgical Clock: The clock displays elapsed time from the start of the surgery. Surgeons always work carefully, while trying to avoid unnecessarily prolonging an operation. The IV Bottle: The IV bottle shows the type and remaining quantity of fluid being infused into the patient. IV bottles should not be allowed to empty, since the injection point may become clotted and hinder further IV administration. A steady flow of glucose solution should be administered to the patient even when a specific transfusion is unnecessary. Anaesthetic: The anaesthetic dial displays the status of the anaesthetic valve. Generally, if the dial points to "on," the valve is open, and the patient is being anaesthetized. If the dial points to "off," the valve is closed, anaesthetic is not being introduced into the respiration chamber, and the patient is breathing only oxygen-rich air. Making sure the patient is fully anaesthetized before commencing the operation is intensely important to any surgeon. The alternative is quite uncomfortable for the patient. Page 11 \/ Chapter Five: Basic Surgical Techniques and the Abdominal Area In this chapter, we will look at the basic structure of the abdominal cavity and the organs and muscle groups found there. Then, we will discuss the general procedure for surgery in the abdominal area, around which specific operations can be built. Finally, we will look at two surgeries that take place in the abdominal area: the appendectomy and the aneurysm graft. Both surgeries make use of the general procedure as a frame for the particular techniques involved. Basics of the Abdomen The human body has several layers of tissue surrounding the skeleton and internal organs. The outermost layer, known commonly as the skin, protects the body from viral and bacterial infections. The fatty layers underneath store excess nutrients for later use. Muscles provide strength and structure. Tissue Layers Skin: The inner vascular, sensitive dermis and dead outer epidermis comprise the skin layer. The skin provides a protective cover that holds the body together. Subcutaneous fat: Fat is adipose tissue, containing cells distended with oil, that stored excess nutrients for use by the body. The subcutaneous fat layer covers the lower frontal abdomen just below the skin. Muscle Groups Rectus abdominus: The rectus abdominus is a muscle group just below the subcutaneous fat layer. Known as the stomach muscles by laypersons, the rectus abdominus is characterized by the rippling effect visible across the abdomen. Linea Alba: The thin connective tissue between the left and right halves of the rectus abdominus is called the linea alba. If is often incised vertically to provide access through the rectus abdominus to the abdomen. External Oblique: These muscle groups, one on the right and one on the left, cover the sides of the abdominal wall from the bottom of the ribs to the top of the pelvis. Transversus Abdominus: Lying just below the external oblique, the transversus muscle tissue connects at the top of the pelvis and the side of the stomach. The muscle cells run at right angles to those of the external oblique. Preperitoneum: The preperitoneum is a delicate opaque membranous tissue separating the Page 12 \/ abdominal muscle layers and the organs of the abdomen. Postperitoneum: This thin membranous tissue, located just below the intestines, covers and protects the kidneys and aorta. Organs Intestines: One of the major organs of the abdomen, the intestines are responsible for the digestion of food and compacting of waste. The small intestine secretes gastric juices to break down food particles into valuable nutrients. The large intestine compacts waste food material for expulsion. Aorta: The aorta is the largest artery in the body. It is the major vessel carrying blood to the abdomen and legs. Just below the umbilicus or "belly button," and aorta splits into the left and right iliac arteries which transport the blood to the legs. Basic Surgical Techniques The initial and final steps of most surgeries follow a standardized regimen. This procedure can be used as the start and end of most abdominal surgeries. Surface Preparation Thorough cleansing and proper attire are required in an operating theatre. The surgeon must scrub with sterile, antiseptic cleanser, then dress in an approved, sterile surgical gown. The face must be covered with a sterile mask, and a fresh pair of surgical latex gloves must be worn. The patient's skin must be similarly prepared. Scrub the uncovered skin with antiseptic and then cover the unaffected regions with a sterile drape. Initial Medications When you are ready, add anaesthetic to the patient's air mixture. Before incising, inject antibiotics to prevent infection after the operation begins. Keep a steady glucose IV dripping to balance fluid loss. Incising Introduction: The most basic procedure in an operation is the incision and retraction of the top tissue layer. To remove or manipulate an offending organ or appendage, the surgeon must first sever the protective tissue layers which cover it. Since there are numerous levels of tissues, the surgeon must make incisions long enough to allow ample space in which to operate after pulling back the tissue layers. Procedure: The first step in this process is to incise the tissue layer. Generally, this is done with the scalpel. Applying moderate pressure, draw the scalpel downward across the layer. Always incise parallel to the muscle cells to insure proper healing. If the layer is an especially thin or delicate one such as the peritoneal layer, do not use the scalpel to incise. Instead, raise a bit of the tissue with forceps and nick it carefully with the scalpel. Then use the scissors to continue the incision from the Page 13 \/ nicking point. This method protects the peritoneal layer as well as the sensitive organs below. Controlling Bleeders Introduction: If the layer is vascular (containing veins and arteries), it will bleed. The point at which an incision crosses a vein or artery is called a bleeder. These bleeding vessels must be sealed to prevent traumatic blood loss. Use forceps to clamp the bleeders off and temporarily stop the bleeding. Then use either a cauterizer or a ligator to permanently seal each bleeder. Cauterizer: To use a cauterizer, place the tip of the cauterizer on the clamped end of the vessel and coagulate. (For specific instructions, consult your Operating Procedures Manual.) Ligator: To use a ligator, encircle the tip of the clamped bleeder with the ligation string and tie off the bleeder tautly. (For specific instructions, consult your Operating Procedures Manual.) Retracting Once the tissue layer is free of bleeders; it may be retracted. Use the retractors to pull back the incised layer. Slip the blade ends of the retractor into the wound and stretch the tissue apart near the incision. Be sure your incision is long enough before you attempt to retract. If the incision is not long enough, the wound cannot be retracted without damaging the tissue layer. The incise-ligate / cauterize-retract sequence is repeated until the necessary organs or appendages are exposed. Some layers, of course, do not contain blood vessels or arteries, so the ligate / cauterize step is unnecessary. The actual corrective phase of the operation continues at this point. Closing the Patient After the operation is complete and you are ready to close the patient, gently release the retractor blades. You must unretract the tissue layers by sliding the retractor blades together and then removing the retractor (Refer to your Operating Procedures Manual for specific instrument procedure.) At this point, carefully suture the incision closed so the patient's wounds will heal. If you place a suture in an incorrect area, it can be removed with the scissors. You must use enough sutures or the wound will not heal. At the skin level, use adhesive skin strips to close the wound rather than sutures. This helps reduce scarring. Special Techniques In addition to the general surgical techniques described above, each operation requires the mastery of specific techniques to bring it to completion. The rest of this chapter is devoted to discussions of the appendectomy and aneurysm grafting techniques. Page 14 \/ Appendectomy Introduction: The vermiform appendix is located in the lower-right quadrant of the patient's abdomen. Due to its placement and the form of the musculature in this area, you must use diagonal muscle split incisions to reach it. Procedure: Incise from the patient's upper right to lower left, using what is called a McBurneys Incision, through most of the layers. However, take care not to use McBurney's incisions where it may cause incisions to cross muscle tissue. Make certain when incising the peritoneum that the colon is not accidentally punctured. After incising and retracting the peritoneum, take a sample of the abdominal fluids; analysis of this specimen will help you prescribe proper medication during the patient's recuperation. Use suction to remove the abdominal fluid. Gently lift the cecum from the abdominal cavity until the appendix is free. The appendix is just underneath the cecum. To elevate, clamp the appendix at its tip. The mesoappendix membrane must be incised, and the artery running parallel to the appendix must be tied off and severed before the appendix can be removed. Nick the membrane with the scalpel near the cecum alongside the mesenteric artery. Then tie off the mesenteric artery with a suture through the nick you've just made. Carefully sever the mesenteric artery from the appendix with the scalpel at the tip of the clamp. Because the infected appendix is filled with offensive fluid, it should be clamped off. To do so, place a clamp at the base of the appendix and another slightly higher. Then, sew a draw-string suture between the clamps and sever the appendix. To ensure proper healing of the stump, invert it with you hand and suture the end of the cecum closed. After, replace the cecum into the abdomen and close the patient. If the appendix ruptures during the surgery, immediately insert a drain hose into the appendix and allow it to drain. Aneurysm Grafting Introduction: Grafting the aorta is a highly sensitive operation. The aorta is the major blood-carrying vessel in the body. To remove the clot forming the dilation and graft the vessel walls, the aorta must be clamped off, stopping precious blood flow to the legs. As the aorta remains closed longer, the probability of abnormal heart rhythms increases dramatically. Procedure: Begin the operation using standard incisions and retractions. The incision at the rectus abdominus must be made on the linea alba. Be sure not to incise the intestines when cutting the preperitoneum. The intestines must be lifted from the abdomen and stabilized with an intestinal bag so that the preperitoneum can be incised. Use extreme caution when incising the preperitoneum because the aorta underneath could be pierced. There should be ample room to mobilize the aorta past the postperitoneum. Lay rubber tubing under the aorta with your hand. An injection of heparin at this stage will keep the blood from clotting and causing embolisms. Carefully clamp Page 15 \/ the left and right arteries below the aneurysm and the mesenteric artery in the middle of the aorta. Finally, stop the blood flow through the aneurysm by applying a clamp just above the aneurysm. Cut the mesenteric artery close to the aorta and ligate it. The aortal incision should be made along the center of the vessel. This incision must be long enough to remove the clot and insert a graft. Lift the clot from the artery with your hand and insert the dacron graft. Suture the graft ends to the aorta walls, close the aortal incision and suture. The aorta must next be checked for leaks. Release the iliac clamps first and then the aorta clamp to examine the area for bleeding. If the graft leaks, it will need to be resutured. Finish by demobilizing the aorta and closing the patient. Page 16 \/ Appendix: Glossary Anaesthesia: A general anaesthetic produces a total lack of bodily sensation and consciousness. A local anaesthetic blocks the nerves surrounding an area to be operated on so that the sensation of pain cannot reach the brain. Aneurysm: Local dilation or stretching of a blood vessel due to deterioration, injury or disease of the vessel wall. This condition creates a pulsating mass over which a "murmur" sound can be heard. Antibiotic: Antibacterial material, of which penicillin is perhaps the best known, obtained from fungi and bacteria. Antiseptic: A material that is destructive to microorganisms that lead to disease, fermentation or putrefaction. Aorta: The major artery that emanates from the left ventricle of the heart. Artery: A vessel that transports blood from the heart to various tissues in the body. Arthritis: Inflammation of joints and / or the surrounding tissues. Atropine: A drug introduced prior to anaesthetic to lessen the secretion in both bronchial and salivary systems and to prevent cardiac depression by quickening the heartbeat. Bacteria: Bacteria are a group of microorganisms. The average size of these small cells is approximately one micron in transverse diameter. Some are pathogenic (disease-producing) to humans. Blood Pressure: The blood pressure is the measure of pressure the heart exerts on the blood vessel walls as it pushes blood through them. It is expressed in two numbers, the systolic pressure and the diastolic pressure. The systolic pressure, the peak level, measures the maximum pressure of the blood exerted against the vessel walls as the heart contracts. The diastolic pressure represents the force of blood exerted against the walls as the heart relaxes. Bradycardia: A retarded rate of heart contraction producing a slowed pulse rate. Calculus (calcuci): An abnormal cohesion of mineral substances that can form in Page 17 \/ the passageways that transmit the body's secretions, or in the organs that serve as reservoirs for them. Renal calculi are those located within the kidney. Cauterizer: An instrument that uses a heated filament to burn or scar tissues and thus coagulate bleeding blood vessels. Cecum: The roughly 6 cm cul-de-sac that lies below the terminal ileum forming the first part of the large intestine. Clamp: An instrument used in surgery to grasp, join, compress or support an organ, tissue or vessel. Coagulate: Changing a substance from a fluid to a gel, to clot. Dacron Graft: A smooth, pliable plastic tube that is placed within the aorta in order to stabilize the artery well. Dopamine: Dopamine is a stimulant used to reverse radical drops in blood pressure. Drain: The drain is used to siphon offensive fluid from a wound, or in the case of an appendectomy, the appendix. Insert the end of the drain into the incision and let the fluid drain out. Remove the drain when the fluid has been removed. Electrocardiogram: The record (also referred to as an EKG) made by an electrocardiograph, an instrument that receives the electrical current produced by a heart's contraction and records it on a moving drum of graph paper or L.E.D. display. Embolism: A solid mass, clot or bubble obstructing a blood vessel. Fluid Vial: A receptacle used to hold a patient's bodily fluids often taken during an operation. Forceps: An instrument used for holding, seizing or retracting. Gauze: A thin, meshed material used in a multitude of surgical procedures. Glucose: Dextrose, blood sugar, corn sugar, grape sugar or starch sugar. Page 18 \/ In this form, carbohydrates are absorbed through the intestinal tract and carried by the blood throughout the body. Heparin: A fast-acting anticoagulant drug. Intestinal Bag: A receptacle, sometimes called a "gut bag," used during an operation to hold the intestines out of the way of the surgeon as he or she operates. Intravenous catheter: A hollow tube of variable length used to introduce fluids into the body, by way of the veins. IV Bottle: A container for fluid that is fed into the body intravenously (through a vein). Kidney Stones: Small precipitates, calculi, composed of mineral salts extracted from urine. These "stones" often become lodged in the ducts of the kidneys. Lidocaine: A local anaesthetic recognized as effective as an antiarrhythmic agent. Ligator: An instrument used to bind or tie vessels that are deep or nearly inaccessible. Lumen: The smooth interior of a tube such as an artery or intestine. Palpate: To feel or examine by touch. Pelvis: The bony, saucer-shaped cavity that protects the bladder, rectum and reproductive organs. Precipitate: A deposit of solid matter that has separated or settled from a solution. Premature Ventricular Contraction: Also known as PVC, results from the premature contraction of the ventricles (lower chambers of the heart.) This "early" or "weak" beat of the heart causes an irregular pulse. Retractors: An instrument for drawing aside the edges of a wound. Saline: Relating to or containing salt, salty. Scalpel: A pointed knife with a convex edge. Scissors: Very delicate layers of tissue are cut using scissors. This instrument is often used instead of a scalpel because scissors can cut tissues without applying pressure to the tender organs underneath. Page 19 \/ Skin Clips: Small plastic adhesive clips used to hold the skin layer closed after incising. Suction: The suction is a small vacuum hose for removing oily fluids. Deposits of blood or infected fluid can be removed by applying the suction tip to the affected area. Suture: The material, often nylon or cat gut, used to unite two surfaces of tissue by means of a stitch. Thrombosis: The formation of a blood clot or clots within the chambers of the heart or in a blood vessel. Ultrasonic scan: Sound vibrations of a high frequency focused into a beam whose echoes provide diagnostic information about the body's different physical properties. Ventricular Fibrillation: An uncoordinated quivering, as opposed to any kind of synchronized beat, of the heart's ventricles (the two lower chambers of the heart). This condition is usually fatal. Vermiform: Slender and worm-like in structure. X-ray: Short rays of the electromagnetic spectrum that are passed through the body and then captured on photographic film. X-rays are often used to examine irregularities in skeletal formation.