Surgery: Cardiothoracic, neurosurgery and plastic surgery

🩺 Cardiothoracic, neurosurgery and plastic surgery -page 11 (the last) of the Surgery chapter. These are specialist areas, but every doctor meets their patients -on the ward after heart surgery, in ED with a sudden headache, or with a wound that won't heal. Focus on who to refer, how urgently, and what can go wrong afterwards. The medical side of heart disease, stroke and skin cancer is in the Cardiology, Neurology and Dermatology chapters.
Your four questions for every patient: Is there an emergency (tamponade, raised intracranial pressure, a failing flap, necrotising infection)? Which specialist needs to know -and how fast? What complications are typical of this operation? What does the patient need for recovery -rehabilitation, wound care, driving advice, medicines?

---

Coronary Artery Bypass Grafting

• CABG -bypasses narrowed coronary arteries using grafts:
  • Left internal mammary (thoracic) artery to the left anterior descending -the best graft (over 90% open at 10 years).
  • Great saphenous vein grafts (less durable), radial artery grafts.
  • Usually through a median sternotomy with cardiopulmonary bypass ("on-pump"); "off-pump" in some.
• CABG rather than PCI (stents) is generally preferred for (heart team decision):
  • Left main stem disease.
  • Three-vessel disease, especially with diabetes or reduced LV function.
  • Complex anatomy (high SYNTAX score).
• Before surgery -stop P2Y12 inhibitors (clopidogrel and ticagrelor 5 days, prasugrel 7 days) where possible; usually continue aspirin; stop DOACs; optimise anaemia, diabetes and smoking; dental check before valve surgery.
• Risk assessment -EuroSCORE II estimates operative mortality.
• Outcomes -relieves angina and improves survival in high-risk anatomy; secondary prevention continues for life (aspirin, statin, BP control, cardiac rehabilitation).

Valve Surgery

• Aortic stenosis -intervene when severe and symptomatic (angina, syncope, breathlessness), or severe with reduced LV function:
  • Surgical aortic valve replacement (SAVR) -younger, lower-risk patients, or those needing other cardiac surgery.
  • TAVI (transcatheter aortic valve implantation, usually via the femoral artery) -older or higher-risk patients; increasingly used at lower risk too (heart team decision). Risks -stroke, vascular injury, heart block (pacemaker), paravalvular leak.
• Mitral regurgitation -repair is preferred to replacement where possible (degenerative disease); transcatheter edge-to-edge repair (TEER, e.g. MitraClip) for high-risk patients.
• Mitral stenosis (usually rheumatic) -balloon valvotomy if anatomy suits; otherwise replacement.
• Valve types:

  Valve	Pros and cons	Anticoagulation
  Mechanical	Lasts a lifetime; audible click; younger patients	Lifelong warfarin (target INR depends on valve and site -often 2.5–3.5); DOACs are contraindicated
  Biological (tissue)	Wears out after 10–20 years (faster in the young); older patients or those who can't take warfarin; may later have valve-in-valve TAVI	Aspirin (± warfarin for about 3 months after surgery)

• Prosthetic valve complications -endocarditis (fever in anyone with a prosthetic valve -blood cultures and echo), valve thrombosis (mechanical, poor INR control -breathlessness, loss of click, emboli), haemolysis, paravalvular leak, bleeding from anticoagulation.
• Endocarditis surgery -heart failure from valve destruction, uncontrolled infection (abscess), large vegetations with embolism, prosthetic valve infection.

After Cardiac Surgery

Complication	Features	Management
Bleeding	High chest drain output, falling Hb, shock	Correct clotting (point-of-care tests), blood products; re-exploration if heavy or continuing
Cardiac tamponade	Low BP, rising CVP, falling urine output, sudden drop in drain output (clot), equalising pressures; can be late (days)	Echo; urgent re-sternotomy (may be done at the bedside in arrest -Cardiac Surgical Advanced Life Support)
Atrial fibrillation	Very common (about 30%), days 2–4	Correct potassium and magnesium, beta-blocker or amiodarone, anticoagulate if persistent
Low cardiac output	Low BP, cool peripheries, low urine output, high lactate	Inotropes, pacing (epicardial wires), balloon pump
Heart block	Especially after valve surgery and TAVI	Temporary epicardial pacing; permanent pacemaker if persists
Stroke and delirium	Embolism, low perfusion	Imaging, stroke team; delirium care
AKI	Bypass, low output, contrast, drugs	Fluids, avoid nephrotoxins, renal replacement if needed
Sternal wound infection and mediastinitis	Wound discharge, a clicking, unstable sternum, fever (days to weeks); diabetes, obesity, bilateral mammary grafts	Cultures, antibiotics, debridement, rewiring, flap cover
Post-pericardiotomy syndrome	Weeks later -fever, pleuritic chest pain, pericardial rub, effusion	NSAIDs or colchicine; watch for tamponade
Leg wound problems	Vein harvest site infection or swelling	Wound care, antibiotics

• Cardiac arrest after cardiac surgery (CALS protocol) -for VF or pulseless VT, give up to three stacked shocks before chest compressions; for asystole or severe bradycardia -pace via epicardial wires; emergency resternotomy within about 5 minutes if no response (tamponade or bleeding).
• Recovery -sternal precautions (no heavy lifting or pushing for about 6–12 weeks), cardiac rehabilitation, no driving for about 4 weeks after CABG (car licence; DVLA -longer for HGV), return to work around 6–12 weeks.

Aortic Surgery

• Type A aortic dissection (involves the ascending aorta) -emergency surgery (replacement of the ascending aorta ± arch); mortality without surgery rises about 1–2% per hour in the first day.
  • Presentation -sudden tearing chest pain radiating to the back, BP difference between arms, pulse deficits, new aortic regurgitation murmur, stroke, MI (right coronary), tamponade.
  • CT angiography; control BP and heart rate (IV labetalol) while arranging surgery; avoid thrombolysis (may be mistaken for MI).
• Type B dissection -medical BP control; TEVAR for complications (see the Vascular Surgery page).
• Thoracic aortic aneurysm -often Marfan syndrome, bicuspid aortic valve, Loeys–Dietz, Ehlers–Danlos type IV, hypertension; elective surgery at about 5.5 cm (lower -about 4.5–5.0 cm -in Marfan and bicuspid valves with risk factors); family screening; BP control (beta-blockers or ARBs).
• Aortic root replacement -Bentall procedure (valve and root) or valve-sparing (David procedure).
• Complications -bleeding, stroke, spinal cord ischaemia (paraplegia -descending aorta surgery; CSF drainage reduces risk), kidney failure.

Lung Cancer Surgery

• Surgery offers the best chance of cure for early-stage non-small cell lung cancer (stage I–II and selected stage III).
• Fitness for surgery:
  • Lung function -FEV₁ and TLCO (gas transfer); predicted post-operative values (based on segments removed); cardiopulmonary exercise testing or shuttle walk test if borderline.
  • Cardiac risk -ECG, history, echo if needed.
  • Performance status, frailty, smoking (stop beforehand -prehabilitation).
• Staging before surgery -PET-CT; EBUS (endobronchial ultrasound) node sampling for enlarged or PET-positive mediastinal nodes; brain MRI for higher stages.
• Operations:
  • Lobectomy -standard (often by VATS -video-assisted thoracoscopic surgery -or robotic).
  • Segmentectomy or wedge resection -small tumours or limited lung function.
  • Pneumonectomy -central tumours; highest risk.
• Not fit for surgery -stereotactic ablative radiotherapy (SABR) for early tumours.
• After surgery -adjuvant chemotherapy (stage II–III), targeted treatment (e.g. osimertinib for EGFR mutations), or immunotherapy; neoadjuvant chemo-immunotherapy in some.
• Complications -prolonged air leak, pneumonia, AF, bronchopleural fistula (after pneumonectomy -sudden coughing up of fluid, falling fluid level), empyema, post-thoracotomy pain, respiratory failure.
• Other thoracic surgery -lung metastasectomy, lung volume reduction or endobronchial valves for severe emphysema, thymectomy (myasthenia gravis, thymoma), mesothelioma (mostly non-surgical), lung transplantation.

Pneumothorax, Empyema and Chest Drains

• Surgery for pneumothorax (BTS 2023) -persistent air leak (usually over 3–5 days), recurrent pneumothorax (including the first contralateral one), bilateral pneumothorax, haemopneumothorax, and high-risk occupations (pilots, divers):
  • VATS bullectomy and pleurodesis (pleurectomy or abrasion) -low recurrence.
  • Medical pleurodesis (talc via a drain) for people unfit for surgery.
• Empyema (pus in the pleural space) -pleural fluid pH under 7.2, frank pus, or organisms on Gram stain:
  • Chest drain plus antibiotics; intrapleural tPA and DNase (MIST2) for poorly draining collections.
  • Surgery (VATS or open decortication) if drainage and fibrinolytics fail -refer early (within about 5–7 days of non-response).
• Chest drains:
  • Safe triangle -the lateral edge of pectoralis major, the lateral edge of latissimus dorsi, a line level with the nipple (5th intercostal space), and the axilla at the apex.
  • Insert just above the rib (the neurovascular bundle runs below each rib); ultrasound guidance for fluid (BTS).
  • Swinging (fluid moving with breathing) means the drain is in the pleural space; bubbling means an ongoing air leak.
  • Never clamp a bubbling drain (risk of tension pneumothorax); keep the bottle below the chest.
  • Re-expansion pulmonary oedema -draining a large effusion too fast (limit to about 1.5 L at once).
• Indwelling pleural catheters -for recurrent malignant effusions (drained at home).

Raised Intracranial Pressure and Hydrocephalus

• The skull is a fixed box -brain, blood and CSF; if one increases (tumour, bleed, swelling, blocked CSF), pressure rises (Monro–Kellie doctrine).
• Features of raised ICP -headache (worse lying down and in the morning, worse with coughing or straining), vomiting, papilloedema, falling GCS, third nerve palsy (dilated pupil -uncal herniation), sixth nerve palsy (a false localising sign), Cushing's response (high BP, slow pulse, irregular breathing -late).
• Emergency management -head up 30°, protect the airway (intubate if GCS 8 or less), normal CO₂, hypertonic saline or mannitol, dexamethasone for tumour swelling (not for trauma or stroke), urgent neurosurgery.
• Hydrocephalus:
  • Obstructive (non-communicating) -blockage within the ventricles (tumours, aqueduct stenosis, posterior fossa bleeds).
  • Communicating -poor CSF absorption (after subarachnoid haemorrhage, meningitis).
  • Treatment -external ventricular drain (EVD -emergency), ventriculoperitoneal (VP) shunt, or endoscopic third ventriculostomy.
• Normal pressure hydrocephalus -older people with the triad of gait disturbance (magnetic, shuffling -usually first), urinary incontinence and dementia ("wet, wobbly and wacky"); enlarged ventricles on CT; lumbar drain or tap test, then VP shunt.
• Shunt problems:
  • Blockage -headache, vomiting, drowsiness, symptoms like those before the shunt -urgent neurosurgical review (CT and shunt series X-rays).
  • Infection -fever, wound redness, abdominal pain (peritoneal end) -usually within months of surgery (staphylococci).
  • Over-drainage (headache on standing, subdural collections).
• Idiopathic intracranial hypertension -young obese women, headache, papilloedema, normal imaging, high opening pressure; weight loss, acetazolamide; shunt or optic nerve sheath fenestration if vision is threatened.

Subarachnoid Haemorrhage and Vascular Lesions

• Subarachnoid haemorrhage -most non-traumatic cases from a ruptured berry aneurysm (circle of Willis):
  • Thunderclap headache (worst ever, maximal within 1 minute), vomiting, neck stiffness, photophobia, collapse, seizures, reduced consciousness.
  • CT head -very sensitive within 6 hours; if negative and done after 6 hours -lumbar puncture at least 12 hours after onset (xanthochromia).
  • CT angiography to find the aneurysm.
• Management:
  • Urgent transfer to a neurosurgical centre.
  • Secure the aneurysm -endovascular coiling (preferred for most -ISAT trial) or surgical clipping -ideally within 24–48 hours.
  • Nimodipine 60 mg every 4 hours for 21 days -reduces delayed cerebral ischaemia (vasospasm).
  • BP control before the aneurysm is secured; analgesia; antiemetics; VTE prevention with stockings or pneumatic devices.
• Complications:
  • Rebleeding -highest in the first 24 hours.
  • Hydrocephalus -drowsiness -EVD.
  • Delayed cerebral ischaemia (vasospasm) -days 4–14 -new deficit or drowsiness -keep euvolaemic; endovascular treatment.
  • Hyponatraemia -SIADH or cerebral salt wasting (low volume) -don't fluid restrict.
  • Seizures, cardiac changes (stunned myocardium, arrhythmias).
• Associations of berry aneurysms -adult polycystic kidney disease, coarctation of the aorta, Ehlers–Danlos syndrome, smoking, hypertension, family history (screening for those with 2 or more affected first-degree relatives).
• Unruptured aneurysms -treat or watch depending on size, site, and patient factors.
• Arteriovenous malformations -younger people; haemorrhage or seizures; surgery, embolisation or stereotactic radiosurgery.
• Cavernomas -seizures, small bleeds; often watched.

Brain Tumour Surgery

• Presentation -progressive neurological deficit, new seizures in an adult, headache with features of raised ICP, personality or cognitive change.
• Referral (NICE NG12) -progressive, sub-acute loss of central nervous function → direct-access MRI (or urgent referral); new focal seizures → urgent assessment.
• Common tumours:
  • Metastases -the commonest (lung, breast, melanoma, kidney, colorectal); surgery or stereotactic radiosurgery for one or a few lesions.
  • Glioblastoma -the commonest primary malignant tumour in adults; maximal safe resection, then radiotherapy with temozolomide (Stupp protocol); poor prognosis (median survival about 15 months).
  • Low-grade gliomas -younger adults with seizures; IDH status guides prognosis.
  • Meningioma -benign, extra-axial, women; often found by chance; surgery, radiotherapy or watching.
  • Pituitary adenoma -bitemporal hemianopia, hormone excess or deficiency; trans-sphenoidal surgery (except prolactinomas -dopamine agonists first); risks -CSF leak, diabetes insipidus, hypopituitarism (steroid cover).
  • Vestibular schwannoma (acoustic neuroma) -one-sided hearing loss and tinnitus; bilateral in NF2; watch, radiosurgery or surgery (facial nerve risk).
  • Children -posterior fossa tumours (medulloblastoma, pilocytic astrocytoma, ependymoma) -headache, vomiting, ataxia, hydrocephalus.
• Peri-operative care -dexamethasone for oedema (with a PPI, monitor glucose), seizure prophylaxis or treatment (levetiracetam), awake craniotomy for tumours near speech or motor areas, 5-ALA fluorescence-guided surgery, VTE prophylaxis.
• Driving -DVLA rules depend on tumour type and seizures -patients must be told to stop driving and inform the DVLA (see the Neurology chapters).

Degenerative Spinal Surgery

• Lumbar disc prolapse -sciatica; most settle within 6–12 weeks; microdiscectomy for persistent severe pain, progressive weakness or cauda equina syndrome (emergency).
• Lumbar spinal stenosis -neurogenic claudication; decompression (laminectomy) for severe cases.
• Degenerative cervical myelopathy -the commonest cause of spinal cord problems in adults (often missed):
  • Clumsy hands (dropping things, difficulty with buttons), unsteady gait, numbness, neck pain, later bladder problems.
  • Signs -upper motor neurone signs (hyper-reflexia, Hoffmann's sign, upgoing plantars, clonus), wasting of the small hand muscles.
  • MRI of the cervical spine; refer to spinal surgery; decompression stops progression (moderate to severe or progressive disease).
• Cervical radiculopathy -arm pain in a nerve root distribution (C6 -thumb, C7 -middle finger); most settle; surgery (ACDF -anterior cervical discectomy and fusion) if persistent or weak.
• Spondylolisthesis -one vertebra slips forward on another (L5/S1 in young athletes; L4/5 degenerative); fusion if severe.
• Complications of spinal surgery -dural tear (CSF leak, headache on standing), nerve root injury, infection (discitis), haematoma (new weakness -emergency), recurrent disc prolapse, adjacent segment disease.

Neurosurgical Infections and CSF Leaks

• Brain abscess -from sinus, ear or dental infection, endocarditis, cyanotic heart disease, penetrating injury, or immunosuppression:
  • Headache, fever (not always), focal signs, seizures, raised ICP.
  • CT or MRI -ring-enhancing lesion (differential -tumour, toxoplasmosis in HIV).
  • Aspiration or excision plus prolonged IV antibiotics (e.g. ceftriaxone and metronidazole); find the source. Don't do an LP (risk of coning).
• Subdural empyema -rapid deterioration after sinusitis; emergency drainage.
• Spinal epidural abscess -back pain, fever, then neurological deficit; IV drug use, diabetes; urgent MRI, antibiotics ± surgical decompression.
• Post-operative infections -wound infection, bone flap infection, shunt and EVD infections (meningitis -CSF sampling from the device).
• CSF leaks:
  • CSF rhinorrhoea (clear watery fluid from the nose -test for beta-2 transferrin) after skull base fractures or pituitary surgery; CSF otorrhoea after temporal bone fractures.
  • Risk of meningitis -pneumococcal vaccination; most traumatic leaks stop in days; surgical repair if persistent.
  • Spontaneous intracranial hypotension -headache on standing, relieved by lying flat; MRI; epidural blood patch.

Wound Healing and the Reconstructive Ladder

• Phases of healing -haemostasis (minutes), inflammation (days 1–5), proliferation (granulation tissue, new vessels, collagen -days 3 to 3 weeks), remodelling (weeks to over a year; scar strength reaches about 80% of normal skin).
• Primary intention -wound edges brought together (sutures, glue, staples) -fast, neat scar; secondary intention -left open to heal from the base (contaminated wounds, abscess cavities, pilonidal wounds); delayed primary closure -closed after a few days once clean.
• Factors that slow healing -infection, poor blood supply, smoking, diabetes, malnutrition (protein, vitamin C, zinc), steroids, chemotherapy, radiotherapy, tension, foreign bodies, older age, obesity.
• Laceration care -clean and irrigate, explore for foreign bodies and tendon or nerve injuries, close within about 6–8 hours (longer for the face with good blood supply); tetanus; antibiotics for bites and contaminated wounds.
• Suture removal times (approximate) -face 5 days, scalp 7 days, trunk and arms 7–10 days, legs and back 10–14 days, over joints 14 days.
• The reconstructive ladder -choose the simplest method that will work:
  • Healing by secondary intention (± negative pressure wound therapy).
  • Direct (primary) closure.
  • Skin graft.
  • Local flap.
  • Regional (pedicled) flap.
  • Free flap (microvascular).
• Negative pressure wound therapy ("VAC") -suction dressing that removes fluid and encourages granulation; used for open abdomens, large wounds, before grafting.

Skin Grafts and Flaps

Type	Description	Points
Split-thickness skin graft	Epidermis plus part of the dermis, taken with a dermatome (usually from the thigh); can be meshed to cover more area	Takes well; donor site heals by itself (like a graze); contracts more; poorer cosmetic result; used for burns and large wounds
Full-thickness skin graft	Whole dermis (from behind the ear, above the clavicle, groin); donor site closed directly	Better colour and texture, contracts less; small areas -face, hands
Local flap	Nearby tissue moved with its own blood supply (rotation, advancement, transposition)	Good match; face and skin cancer defects
Pedicled flap	Tissue moved on its named blood vessel (e.g. latissimus dorsi, pectoralis major)	Bigger defects; breast and chest wall reconstruction
Free flap	Tissue detached and its vessels joined to new vessels under the microscope (e.g. DIEP, anterolateral thigh, radial forearm)	Complex reconstruction; open fractures, head and neck cancer, breast

• Grafts need a vascular bed -they take on granulation tissue, muscle and fascia; they won't take on bare bone (without periosteum), bare tendon (without paratenon), cartilage, infected wounds (especially beta-haemolytic streptococcus), or irradiated tissue.
• Graft failure -commonest causes: haematoma or seroma under the graft, shearing (movement), infection.
• Flap monitoring -colour, temperature, capillary refill, Doppler signal (hourly at first):
  • Venous congestion (commonest) -purple, swollen, brisk refill, dark bleeding on pinprick.
  • Arterial insufficiency -pale, cold, slow or no refill, no bleeding on pinprick.
  • A failing free flap is an emergency -return to theatre quickly (salvage is possible within hours); keep the patient warm, well filled, and avoid vasoconstrictors and tight dressings.

Skin Cancer Surgery

• Basal cell carcinoma -pearly, rolled edge, telangiectasia, slow growing, rarely spreads; surgical excision with a 4 mm margin for small well-defined lesions; Mohs micrographic surgery for high-risk sites (central face, around the eyes, nose, lips, ears), recurrent or poorly defined tumours; other options -curettage, cryotherapy, topical treatments, radiotherapy.
• Squamous cell carcinoma -a growing, keratinising, tender nodule or ulcer on sun-damaged skin (also in old scars -Marjolin's ulcer; transplant recipients); excision with 4–6 mm margins (wider for high-risk); can spread to lymph nodes -examine nodes; suspected cancer pathway referral.
• Melanoma:
  • Use the ABCDE or weighted 7-point checklist (major -change in size, shape, colour; minor -diameter 7 mm or more, inflammation, oozing, change in sensation).
  • Excision biopsy with a 2 mm margin first (don't shave or partly biopsy suspicious lesions).
  • Then wide local excision based on Breslow thickness -in situ: 0.5–1 cm; up to 1 mm thick: 1 cm; 1–4 mm: 1–2 cm; over 4 mm: 2–3 cm (follow current NICE NG14 and BAD guidance).
  • Sentinel lymph node biopsy for stage IB and above (staging, not treatment); adjuvant immunotherapy for higher-risk disease.
• Refer -melanoma and SCC on the suspected cancer pathway; BCCs routinely unless in a high-risk site or large (see the Skin Lesions and Cancer chapter).
• Other skin lumps -lipomas (soft, mobile -excise if over 5 cm, deep, growing or painful -consider sarcoma), epidermoid cysts (punctum -excise when not inflamed), keratoacanthoma (fast-growing crater with keratin plug -excise, may be SCC).

Pressure Ulcers

• Damage to skin and underlying tissue from pressure, shear and friction -usually over bony areas (sacrum, heels, hips, ischial tuberosities, back of the head in infants).
• Risk factors -immobility, spinal cord injury, older age, malnutrition, incontinence (moisture), poor circulation, diabetes, sedation, delirium, devices (masks, catheters, casts).
• Risk assessment -validated tools (e.g. Waterlow, Braden, Purpose-T) on admission; skin checks.
• Categories (NPUAP/EPUAP):
  • 1 -non-blanching redness of intact skin.
  • 2 -partial-thickness skin loss (shallow ulcer or blister).
  • 3 -full-thickness skin loss (fat visible, no bone, tendon or muscle).
  • 4 -full-thickness tissue loss with exposed bone, tendon or muscle.
  • Unstageable (base covered by slough or eschar) and deep tissue injury (purple or maroon intact skin).
• Prevention and treatment (NICE CG179) -repositioning (at least every 6 hours for adults at risk, every 4 hours at high risk), pressure-relieving mattresses and heel offloading, skin care and moisture management, nutrition and hydration, treat infection (osteomyelitis under deep ulcers -MRI), debridement; plastic surgery flap reconstruction for selected category 3–4 ulcers.
• Safeguarding -category 3 and 4 ulcers (and some category 2) may need reporting under local safeguarding and patient safety processes.

Necrotising Soft Tissue Infection

• Necrotising fasciitis -a rapidly spreading infection of the fascia and soft tissues -a surgical emergency (mortality about 20–30%).
• Types:
  • Type 1 (polymicrobial) -mixed aerobes and anaerobes -older people, diabetes, after surgery; includes Fournier's gangrene (perineum).
  • Type 2 (monomicrobial) -group A streptococcus (± staphylococcus) -healthy people after minor injuries, IV drug users, chickenpox in children; toxic shock.
  • Gas gangrene (clostridial myonecrosis) -deep contaminated wounds; crepitus, bronze skin.
• Early features -pain out of proportion to the visible signs, rapid spread, tense swelling beyond the redness, high fever, tachycardia; looks like cellulitis but the patient is much sicker.
• Later features -dusky or purple skin, blisters (haemorrhagic bullae), crepitus, skin numbness, necrosis, shock and multi-organ failure.
• LRINEC score (CRP, WCC, Hb, sodium, creatinine, glucose) may help -but a low score doesn't exclude it; clinical suspicion is key.
• Management:
  • Urgent surgical debridement -the most important treatment; "dishwater" fluid and fascia that separates easily ("finger test"); repeat debridement every 24–48 hours.
  • Broad-spectrum IV antibiotics including clindamycin (stops toxin production) -e.g. piperacillin–tazobactam (or meropenem) with clindamycin per local policy; IVIG in streptococcal toxic shock (specialist).
  • Don't delay surgery for imaging; ICU care; later reconstruction (grafts and flaps).
  • Group A streptococcus -notify UKHSA; close contacts may need prophylaxis.

Scars, Keloids and Cleft Lip and Palate

• Hypertrophic scars -raised, red, stay within the wound edges; appear within weeks; often improve over 1–2 years; burns, wounds under tension, infection.
• Keloid scars -grow beyond the wound edges, may appear months later, rarely regress; more common in darker skin and on the earlobes, chest, shoulders and upper back; often recur after excision.
• Treatment of problem scars -silicone gel or sheets, pressure garments (burns), intralesional steroid (triamcinolone), laser, cryotherapy; keloid excision combined with steroid injection or radiotherapy (to reduce recurrence).
• Scar contractures -tight scars across joints (burns) -Z-plasty, release and grafting, physiotherapy and splints.
• Langer's lines (skin tension lines) -incisions along them heal with neater scars.
• Cleft lip and palate:
  • One of the commonest birth differences (about 1 in 700 UK births); cleft lip ± palate, or isolated cleft palate (more associated with syndromes, e.g. 22q11 deletion, Pierre Robin sequence).
  • Risk factors -family history, maternal smoking, anticonvulsants (phenytoin, valproate), folate deficiency.
  • Problems -feeding (specialist bottles and teats; isolated cleft palate can be missed -examine the palate in every newborn), speech, hearing (glue ear -grommets), dental problems, appearance and psychological impact.
  • Care -a regional cleft team; lip repair at about 3 months; palate repair by about 6–12 months; speech therapy, alveolar bone grafting (age 8–11), orthodontics and later surgery.

Specialist Surgery at a Glance

Condition	Key clues	Management
Left main stem or 3-vessel disease with diabetes	Angiography findings	CABG (heart team)
Severe symptomatic aortic stenosis	Syncope, angina, breathlessness	SAVR or TAVI
Tamponade after cardiac surgery	Low BP, rising CVP, drain output stops	Echo, urgent resternotomy
Mechanical valve	Metallic click	Lifelong warfarin -no DOACs
Type A dissection	Tearing chest pain to the back, arm BP difference	CT angiography, emergency surgery
Early lung cancer, fit	Stage I–II NSCLC, adequate FEV1 and TLCO	Lobectomy (VATS); SABR if unfit
Empyema	Pleural pH under 7.2, pus	Chest drain, antibiotics, tPA/DNase, surgery if failing
Subarachnoid haemorrhage	Thunderclap headache, CT or xanthochromia	CTA, coiling or clipping, nimodipine
Normal pressure hydrocephalus	Gait, incontinence, dementia	Tap test, VP shunt
Blocked VP shunt	Headache, vomiting, drowsiness	Urgent neurosurgical review
Degenerative cervical myelopathy	Clumsy hands, unsteady gait, UMN signs	MRI, decompression
Brain abscess	Fever, focal signs, ring-enhancing lesion	Aspiration, IV antibiotics, no LP
Failing flap -venous	Purple, swollen, brisk refill	Return to theatre
Necrotising fasciitis	Pain out of proportion, rapid spread	Urgent debridement, antibiotics with clindamycin
Keloid	Scar growing beyond the wound edge	Silicone, steroid injection

Spot the Diagnosis

Clue	Diagnosis
Best long-term coronary graft	Left internal mammary artery to LAD
Irregular pulse on day 3 after CABG	Post-operative atrial fibrillation
Falling BP, rising CVP and sudden drop in drain output 6 hours after cardiac surgery	Cardiac tamponade
Clicking, discharging sternum 2 weeks after CABG	Sternal wound infection or mediastinitis
Fever, pleuritic pain and pericardial rub 3 weeks after cardiac surgery	Post-pericardiotomy syndrome
Complete heart block after TAVI	Conduction injury -pacemaker
Loss of valve click with breathlessness and a low INR	Mechanical valve thrombosis
Tall man with a 4.8 cm aortic root and a family history of sudden death	Marfan syndrome -consider surgery
Paraplegia after thoracoabdominal aneurysm repair	Spinal cord ischaemia
Coughing up large amounts of fluid a week after pneumonectomy	Bronchopleural fistula
Second pneumothorax on the same side in a 24-year-old	Refer for VATS pleurodesis
Breathlessness and pink frothy sputum after draining 3 L from the chest	Re-expansion pulmonary oedema
Dilated pupil and falling GCS with a growing tumour	Uncal herniation (third nerve)
Shuffling gait, urinary incontinence and memory loss in a 75-year-old	Normal pressure hydrocephalus
Headache, vomiting and drowsiness in a child with a VP shunt	Shunt blockage
Thunderclap headache with xanthochromia at 12 hours	Subarachnoid haemorrhage
New weakness on day 7 after SAH coiling	Delayed cerebral ischaemia (vasospasm)
Low sodium and low volume after SAH	Cerebral salt wasting -don't restrict fluids
Berry aneurysm in a patient with enlarged cystic kidneys	Adult polycystic kidney disease
Polyuria with low urine osmolality after pituitary surgery	Cranial diabetes insipidus
One-sided hearing loss and tinnitus with a cerebellopontine angle mass	Vestibular schwannoma
Dropping things and positive Hoffmann's sign in a 65-year-old	Degenerative cervical myelopathy
Ring-enhancing lesion after a dental abscess	Brain abscess
Clear nasal discharge positive for beta-2 transferrin after a head injury	CSF rhinorrhoea
Skin graft lost over exposed tendon without paratenon	Poor graft bed
Purple, swollen free flap with brisk refill	Venous congestion
Pale, cold flap with no bleeding on pinprick	Arterial insufficiency
Pearly nodule with rolled edges beside the nose	BCC -consider Mohs surgery
Growing ulcer in a 30-year-old burn scar	Marjolin's ulcer (SCC)
Purple intact skin over the sacrum of a bed-bound patient	Deep tissue pressure injury
Pain out of proportion with spreading redness and shock after a minor cut	Necrotising fasciitis (group A strep)
Scar spreading beyond the wound on the earlobe after piercing	Keloid
Milk coming out of the nose during feeds in a newborn	Cleft palate

Exam-style Scenarios

1. A 66-year-old man is on the cardiac ICU 5 hours after CABG. His BP has fallen from 120/70 to 80/50 over an hour, CVP has risen from 8 to 18 mmHg, and his chest drains, which were draining 150 mL an hour, have suddenly stopped.
Answer: Cardiac tamponade (clotted drains).

• Call the cardiac surgeon immediately; check drains for clot; bedside echo.
• Fluids and inotropes as a temporary support; correct clotting; blood products.
• Urgent re-sternotomy (in theatre, or at the bedside if he arrests -follow CALS).

2. A 49-year-old woman has a sudden severe occipital headache while lifting shopping, "like being hit with a bat". She vomited and has neck stiffness. GCS 15. CT head at 3 hours shows blood in the basal cisterns.
Answer: Subarachnoid haemorrhage.

• CT angiography and urgent referral to the neurosurgical centre; analgesia, antiemetics, BP control (before the aneurysm is secured).
• Nimodipine 60 mg every 4 hours for 21 days; keep euvolaemic; monitor sodium.
• Endovascular coiling (or clipping) as soon as possible; watch for rebleeding, hydrocephalus and delayed cerebral ischaemia.

3. A 72-year-old man has a year of increasingly clumsy hands -he can't do up buttons -and is unsteady when walking. He has brisk reflexes in all four limbs, positive Hoffmann's signs and wasting of the small muscles of the hands.
Answer: Degenerative cervical myelopathy.

• MRI cervical spine (cord compression, signal change).
• Refer to spinal surgery -decompression (anterior or posterior) for moderate, severe or progressive myelopathy.
• Advise avoiding neck manipulation; physiotherapy and falls prevention while waiting; recovery of lost function is limited -the aim is to stop progression.

4. A 30-year-old man scratches his shin on a fence. Twenty-four hours later the leg is very painful and swollen with patchy redness and a purple blister. HR 130, BP 85/50, temperature 39.4°C. The pain is far worse than the appearance suggests.
Answer: Necrotising fasciitis (probably group A streptococcus) with septic shock.

• Sepsis Six; IV antibiotics including clindamycin (per local policy, e.g. with piperacillin–tazobactam or benzylpenicillin); resuscitation.
• Emergency surgical debridement -don't wait for imaging or a scoring tool; repeat debridement in 24–48 hours.
• ICU care; notify UKHSA (invasive group A strep); later reconstruction with skin grafts.

5. A 58-year-old woman had a free flap breast reconstruction (DIEP) 8 hours ago. The nurse reports the flap has become purple and swollen; capillary refill is very brisk and a pinprick produces dark blood.
Answer: Failing free flap from venous congestion.

• Call the plastic surgeon immediately -return to theatre for exploration of the venous anastomosis (salvage is time-critical).
• Meanwhile -loosen tight dressings or garments, check positioning (no pressure on the pedicle), keep the patient warm and well filled, avoid vasoconstrictors.
• Check Hb and clotting; consider a haematoma compressing the vessels.

Key Points

• CABG is generally preferred to stents for left main stem and three-vessel disease, especially with diabetes.
• Severe symptomatic aortic stenosis -SAVR or TAVI (heart team); TAVI can cause heart block.
• Mechanical valves need lifelong warfarin -DOACs are contraindicated.
• After cardiac surgery -AF is common; tamponade causes low BP, high CVP and a sudden drop in drain output.
• Cardiac arrest after cardiac surgery -three stacked shocks, pacing, early resternotomy.
• Type A dissection -emergency surgery; don't thrombolyse.
• Lung cancer surgery needs FEV₁, TLCO, PET-CT and EBUS; SABR if unfit.
• Insert chest drains in the safe triangle above the rib; never clamp a bubbling drain.
• Raised ICP -headache, vomiting, papilloedema, falling GCS; dexamethasone for tumour oedema only.
• Normal pressure hydrocephalus -gait, incontinence, dementia; VP shunt.
• Shunt patient with headache, vomiting or drowsiness -urgent neurosurgical review.
• SAH -CT, then LP at 12 hours if needed; coiling; nimodipine for 21 days.
• Degenerative cervical myelopathy -clumsy hands, gait problems, UMN signs -MRI and decompression.
• Brain abscess -ring-enhancing lesion, aspirate, antibiotics, no LP.
• Reconstructive ladder -simplest method that works; grafts need a vascular bed.
• Free flap -purple and swollen is venous, pale and cold is arterial -return to theatre fast.
• Melanoma -2 mm margin excision biopsy, then wide excision by Breslow thickness.
• Pressure ulcers -reposition, offload, nutrition; category 4 exposes bone, tendon or muscle.
• Necrotising fasciitis -pain out of proportion; urgent debridement plus clindamycin.
• Keloids grow beyond the wound edge; hypertrophic scars stay within it.

Guidelines and Further Reading

• ESC/EACTS: Guidelines on myocardial revascularisation; Guidelines for the management of valvular heart disease
• NICE NG208: Heart valve disease presenting in adults
• European Association for Cardio-Thoracic Surgery: Resuscitation after cardiac surgery (CALS)
• DVLA: Assessing fitness to drive -cardiovascular and neurological disorders
• NICE NG122: Lung cancer -diagnosis and management
• British Thoracic Society: Pleural disease guideline (2023)
• NICE NG228: Subarachnoid haemorrhage caused by a ruptured aneurysm
• NICE NG99: Brain tumours (primary) and brain metastases in over 16s
• Myelopathy.org and AO Spine: Guidelines for degenerative cervical myelopathy
• NICE NG14: Melanoma -assessment and management; British Association of Dermatologists: BCC and cSCC guidelines
• NICE CG179: Pressure ulcers -prevention and management
• UKHSA: Management of invasive group A streptococcal infections
• CLAPA and the Cleft Registry and Audit Network (CRANE)
• BNF -for current doses