Laparoscopic surgery involves insufflation of a gas (usually carbon dioxide) into the peritoneal cavity producing a pneumoperitoneum. This causes an increase in intra-abdominal pressure (IAP). Carbon dioxide is insufflated into the peritoneal cavity at a rate of 4–6 litre min−1 to a pressure of 10–20 mm Hg. The pneumoperitoneum is maintained by a constant gas flow of 200–400 ml min−1.

Carbon dioxide is the most frequently used gas for insufflation of the abdomen as it is colourless, non-toxic, non-flammable and has the greatest margin of safety in the event of a venous embolus (highly soluble). It is absorbed readily from the peritoneum, causing an increase in PaCO2. This has direct, as well as indirect (by raising catecholamine levels), effects on the cardiovascular system. Thus, tachycardia, increased cardiac contractility and reduction in the diastolic filling can result in decreased myocardial oxygen supply to demand ratio and greater risk of myocardial ischaemia.

Laminar flow theatres aim to reduce the number of infective organisms in the theatre air by generating a continuous flow of bacteria free air. In laminar flow theatres air may be ‘changed’ in theatre more than 300 times per hour compared to standard positive pressure theatre rates of 15-25 air changes per hour.
Shaving skin on the ward increases infection rates and extended chemoprophylaxis increases the risk of antibiotic associated diarrhoea

Medial extension of an appendicectomy incision carries a risk of injury to the inferior epigastric artery which can bleed briskly. It is best managed by ligation.

Bleeding is a complication encountered in all branches of surgery. The decision as to how best to manage the bleed, depends upon its site, vessel, and circumstances.

1. Superficial dermal bleeding:
This will usually cease spontaneously. If not, then direct use of a monopolar or a bipolar cautery device will usually control the situation. Scalp wounds are a notable exception and bleeding from them may be brisk. In this situation, use of a mattress suture as a wound closure method will usually address the problem.

2. Superficial arterial bleeding:
If the vessel can be safely identified in superficial arterial bleeding, then the easiest method is to apply a haemostatic clip and ligate the vessel.

3. Major arterial bleeding:
If the vessel can be clearly identified and is accessible, then it may be possible to apply a clip and ligate the vessel. If the vessel is located in a pool of blood, then blind application of haemostatic clips is highly dangerous and may result in collateral injury. In this situation, evacuating the clot and packing the area is often safer. The pack can then be carefully removed when the required instruments are available. Some vessels may retract and bleeding may then be controlled by dissection of surrounding structures or underrunning the bleeding point.

4. Major venous bleeding:
The safest initial course of action is to apply digital pressure to the bleeding point. To control the bleeding, thereafter, the surgeon will need a working suction device. Divided veins may require ligation.

5. Bleeding from raw surfaces:
This may be mixed bleeding and can be troublesome. Spray diathermy and argon plasma coagulation are both useful agents. Certain topical haemostatic agents, such as surgicel, are useful in encouraging clot formation and may be used in conjunction with, or instead of, the above agents.

Post-operative fever is very common.
It is known to occur after all types of surgical procedures, irrespective of the type of anaesthesia.
Postoperative fever can occur after minor surgical procedures but is rare and depends on the type of procedure. Overall, both abdominal and chest procedures result in the highest incidence of postoperative fever.

In this case:
Acute Fever
Fever occurs in the first week (1 to 7 POD)
POD 7 (5 to 10): Wound infection: Risk increases if the patient is immunocompromised (e.g., diabetic), abdominal wound, duration of surgery greater than 2 hours or contamination during surgery. Signs include erythema, warmth, tenderness, discharge.
Rule out abscess or collections by physical exam plus ultrasound if needed. If an abscess is present, drainage and antibiotics are needed. Prevention is by careful surgical technique and prophylactic antibiotics (e.g., intravenous cefazolin at the time of induction of anaesthesia as well as postoperatively if needed)

Other causes of Postoperative fever:
An Immediate Fever
Fever occurs immediately after surgery or within hours on postoperative days (POD) 0 or 1.
– Malignant hyperthermia: high-grade fever (greater than 40 C), occurs shortly after inhalational anaesthetics or muscle relaxant (e.g., halothane or succinylcholine), may have a family history of death after anaesthesia. Laboratory studies will reveal with metabolic acidosis and hypercalcemia. If not readily recognized, it can cause cardiac arrest. The treatment is intravenous dantrolene, 100% oxygen, correction of acidosis, cooling blankets, and watching for myoglobinuria.
– Bacteraemia: High-grade fever (greater than 40 C) occurring 30 to 40 minutes after the beginning of the procedure (e.g., Urinary tract instrumentation in the presence of infected urine). Management includes blood cultures three times and starting empiric antibiotics.
– Gas gangrene of the wound: High-grade fever (greater than 40 C) occurring after gastrointestinal (GI) surgery due to contamination with Clostridium perfringens; severe wound pain; treat with surgical debridement and antibiotics.
– Febrile non-haemolytic transfusion reaction: Fevers, chills, and malaise 1 to 6 hours after surgery (without haemolysis). Management: Stop transfusion (rule out haemolytic transfusion reaction) and give antipyretics (avoid aspirin in the thrombocytopenic patient).

B. Acute Fever
– Fever occurs in the first week (1 to 7 POD).
POD 1 to 3: atelectasis: After prolonged intubation, the presence of upper abdominal incision, inadequate postoperative pain control, lying supine. Should be prevented by incentive spirometry, semi-recumbent position, adequate pain control, early ambulation. Clinically may be asymptomatic or with increased work of breathing, respiratory alkalosis, chest x-ray with volume loss. Treatment includes spirometry, chest physiotherapy, semi-recumbent position (improves expansion of alveoli by preventing pressure from intra-abdominal organs on the diaphragm and hence improving functional residual capacity)
– POD 3: Unresolved atelectasis resulting in pneumonia (respiratory symptoms, Chest x-ray with infiltrate or consolidation, sputum culture, empiric antibiotics and modify according to culture result and sensitivity), or development of urinary tract infection (urine analysis and culture, treat with empiric antibiotics and modify according to culture result and sensitivity)
– POD 5: Thrombophlebitis (may be asymptomatic or symptomatic, diagnose with Doppler ultrasound of deep leg and pelvic veins and treat with heparin)
– POD 7: Pulmonary embolism (tachycardia, tachypnoea, pleuritic chest pain, ECG with right heart strain pattern (a low central venous pressure goes against diagnosis), arterial blood gas with hypoxemia and hypocapnia, confirm diagnosis with CT angiogram, and treat with heparin, if recurrent pulmonary embolism while anticoagulated with therapeutic INR, Inferior vena cava filter placement is the next step

C. Subacute Fever
Fever occurs between postoperative weeks 1 and 4.
– POD 10: Deep infection (pelvic or abdominal abscess and if abdominal abscess could be sub-hepatic or sub-phrenic). A digital rectal exam to rule out the pelvic abscess and CT scan to localize intra-abdominal abscess. Treatment includes re-exploration vs. radiological guided percutaneous drainage
Drugs: Diagnosis of exclusion includes rash and peripheral eosinophilia

D. Delayed Fever
Fever after more than 4 weeks.
Skin and soft tissue infections (SSTI)
Viral infections

Burn depth is classified as first, second, third, or fourth degree, as follows:
First-degree burns are usually red, dry, and painful. Burns initially termed first-degree are often actually superficial second-degree burns, with sloughing occurring the next day.
Second-degree burns are often red, wet, and very painful. Their depth, ability to heal, and propensity to form hypertrophic scars vary enormously.
Third-degree burns are generally leathery in consistency, dry, insensate, and waxy. These wounds will not heal, except by contraction and limited epithelial migration, with resulting hypertrophic and unstable cover. Burn blisters can overlie both second- and third-degree burns. The management of burn blisters remains controversial, yet intact blisters help greatly with pain control. Debride blisters if infection occurs.
Fourth-degree burns involve underlying subcutaneous tissue, tendon, or bone. Usually, even an experienced examiner has difficulty accurately determining burn depth during an early examination. As a general rule, burn depth is underestimated upon initial examination.

The management plan for patients with large burns that require inpatient care is usually determined by the physiology of the burn injury.
Hospitalization is divided into 4 general phases, including (1) initial evaluation and resuscitation, (2) initial wound excision and biologic closure, (3) definitive wound closure, and (4) rehabilitation and reconstruction.

Early excision and closure of full-thickness wounds change the natural history of burn injury, avoiding the otherwise common occurrence of wound sepsis. Wound size is the most important factor in determining the need for early operation

Medications
See the list below:
– Silver sulfadiazine – Broad antibacterial spectrum; painless application
– Aqueous 0.5% silver nitrate – Broad-spectrum coverage, including fungi; leeches electrolytes
– Mafenide acetate – Broad antibacterial spectrum; penetrates eschar best
– Petrolatum – Bland and nontoxic
– Various debriding enzymes – Useful in selected partial-thickness wounds
– Various antibiotic ointments – Useful in many superficial partial-thickness wounds
Membranes
See the list below:
– Porcine xenograft – Adheres to wound coagulum and provides excellent pain control
– Split-thickness allograft – Vascularizes and provides durable temporary closure of wounds
– Various hydrocolloid dressings – Provide vapour and bacteria barrier while absorbing wound exudate
– Various impregnated gauzes – Provide vapour and bacteria barrier while allowing drainage
– Various semipermeable membranes – Provide vapour and bacteria barrier
– Acticoat (Westhaim Biomedical, Saskatchewan, Canada) – Nonadherent wound dressing that delivers a low concentration of silver for antisepsis
– Biobrane (Dow-Hickman, Sugarland, Tex) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer and provides temporary vapour and bacteria barrier
– Transcyte (Smith and Nephew, Largo, Fla) – Synthetic bilaminate that facilitates fibrovascular tissue growth into the inner layer populated with allogenic fibroblasts and overlying layer that provides temporary vapour and bacteria barrier
– AlloDerm R – Consists of cell-free allogenic human dermis; requires an immediate thin overlying autograft
– Integra R – Provides scaffold for neodermis; requires delayed thin autograft

Carcinoid syndrome occurs in ∼20% of cases of well-differentiated endocrine tumours of the jejunum or ileum (midgut neuroendocrine tumours (NET) and consists of (usually) dry flushing (without sweating; 70% of cases) with or without palpitations, diarrhoea (50% of cases) and intermittent abdominal pain (40% of cases); in some patients, there is also lacrimation and rhinorrhoea.
Carcinoid syndrome occurs less often with NETs of other origins and is very rare in association with rectal NETs. It is usually due to metastasis to the liver, with the release of vasoactive compounds, including biogenic amines (e.g., serotonin and tachykinins), into the systemic circulation. However, it may also occur in the absence of liver metastases if there is direct retroperitoneal involvement, with venous drainage bypassing the liver. Pain due to hepatic enlargement may also be a presenting feature, as may upper right abdominal pain (similar to that of pulmonary infarction) secondary to either haemorrhage into, or necrosis of, a hepatic secondary tumour. Wheezing and pellagra are less common presenting features. CHD is present in ∼20% of patients at presentation and usually indicates that the syndrome has been present for several years.

The aim of treatment should be curative where possible but it is palliative in the majority of cases.
Surgery is the only curative treatment.
Administration of specific medications to treat symptoms should, therefore, start as soon as clinical and biochemical signs indicate the presence of hypersecretory NETs, even before the precise localisation of primary and metastatic lesions is confirmed.

The only proven hormonal management of NETs is by the administration of somatostatin analogues.
Somatostatin analogues bind principally to SSTR subtypes 2 (with high affinity) and 5 (with lower affinity), thus inhibiting the release of various peptide hormones in the gut, pancreas and pituitary; they also antagonise growth factor effects on tumour cells, and, at very high dosage, may induce apoptosis. The effects of somatostatin analogues are demonstrable as biochemical response rates (inhibition of hormone production) in 30–70% of patients and as symptomatic control in the majority of patients.
There are two commercially available somatostatin analogues: octreotide and lanreotide.

A pressure of 10 mmHg should be set on the gas insufflation system.

Laparoscopic surgery may be performed in a number of body cavities. In some areas, irrigation solutions are preferred. In the abdomen, however, insufflation with carbon dioxide gas is commonly used. The amount of gas delivered is adjusted to maintain a constant intra-abdominal pressure of 12–15 mmHg. Excessive intra-abdominal pressure may reduce venous return and lead to hypotension. Too little insufflation will risk obscuring the surgical view.

Answer: Excision biopsy of a lymph node

Hodgkin lymphoma is an uncommon cancer that develops in the lymphatic system, which is a network of vessels and glands spread throughout your body. In Hodgkin lymphoma, B-lymphocytes (a particular type of lymphocyte) start to multiply in an abnormal way and begin to collect in certain parts of the lymphatic system, such as the lymph nodes (glands). The affected lymphocytes lose their infection-fighting properties, making you more vulnerable to infection. The most common symptom of Hodgkin lymphoma is a painless swelling in a lymph node, usually in the neck, armpit or groin.
A histologic diagnosis of Hodgkin lymphoma is always required. An excisional lymph node biopsy is recommended because the lymph node architecture is important for histologic classification.

Features of Hodgkin lymphoma include the following:

Asymptomatic lymphadenopathy may be present (above the diaphragm in 80% of patients)

Constitutional symptoms (unexplained weight loss [>10% of total body weight] within the past 6 months, unexplained fever >38º C, or drenching night sweats) are present in 40% of patients; collectively, these are known as B symptoms

Intermittent fever is observed in approximately 35% of cases; infrequently, the classic Pel-Ebstein fever is observed (high fever for 1-2 week, followed by an afebrile period of 1-2 week)

Chest pain, cough, shortness of breath, or a combination of those may be present due to a large mediastinal mass or lung involvement; rarely, haemoptysis occurs

Pruritus may be present

Pain at sites of nodal disease, precipitated by drinking alcohol, occurs in fewer than 10% of patients but is specific for Hodgkin lymphoma

Back or bone pain may rarely occur

A family history is also helpful; in particular, nodular sclerosis Hodgkin lymphoma (NSHL) has a strong genetic component and has often previously been diagnosed in the family.

Active, serious haemorrhage due to Warfarin should be treated with four-factor prothrombin complex concentrate (PCC), if available.
While costly, an essential advantage FFP confers to emergency care is that, in contrast to FFP, it results in a more rapid reversal of coagulopathy and does not require thawing or blood group typing. Additionally, it has a reduced risk of volume overload, transfusion-related acute lung injury, transfusion reactions, and infectious disease transmission. Despite these advantages, no mortality benefit has been proven for PCC compared with FFP.
Alternatively, recombinant factor VIIa (rFVIIa) has been reported to be effective in rapidly lowering INR due to warfarin toxicity and may be considered if PCC is not available. FFP is effective at lowering the INR and was historically first-line therapy for warfarin toxicity with serious or life-threatening bleeding, although it has now been superseded by PCC, which lowers the INR more rapidly. If PCC or rFVIIa is not available, 4 units of FFP may be administered instead.
Administer vitamin K1, 10 mg, by slow IV infusion,

A surgical drain is a tube used to remove pus, blood or other fluids from a wound. They are commonly placed by surgeons or interventional radiologists. Suction is applied through the drain to generate a vacuum and draw fluids into a bottle. Following breast surgery, it is standard practice to use a Redivac type system that is made of polypropylene.