The Surgeon ~~~~~~~~~~~ PAGE 1 1 the "surgeon" is not just an ordinary game. 2 it is a simulation game!!. for those who wanted to be a surgeon, but never had a 3 chance, and for the inspired young enthusiasts, the "surgeon" offers the 4 opportunity to live through the experience of a real surgeon. Even the terminologies 5 used are authentic medical terminologies. 6 it is an educational game!!."the surgeon"allows you to learn the organs and 7 layers of the human body while enjoying the fun of the game. You can also understand 8 the prodedure, and complications that are seen in a real life surgical operation. The 9 steps involved in this operative procedure are as accurate as possible to a real operation 10 of a disease called aneurysm. this can be a valuable assistance to medical students 11 physicians in training, or anyone who wishes to understand the human body and 12 surgical procedures. of course, the complications are dramatized. the "surgeon" is 13 not forgiving (i.e. most mistakes are not tolerated) in reality, some of these mistakes 14 can be corrected 15 and finally a game itself!!there are many traps and dangers like any other 16 games. 'the surgeon' is a game of precision and skill. the whole operation 17 depends upon the precision and accuracy of the surgical incisions. many operations 18 are delicate. a slight error and the results can be fatal. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 2 1 what are the enemies of a surgeon ? 2 infection is the number one enemy for any surgical operation. many times the 3 operation is thought to be successful but only to find out later that the patient succumbs 4 to an infecion. 5 bleeding. cutting the wrong vessels can be dangerous and sometimes 6 fatal. 7 the intestines are usually not clean. they contain with food and germs inside 8 cutting the intestings by accident can contaminate the whole surgical procedure 9 and can lead to infection. 10 the time taken to complete an operation is very critical the longer the 11 operation, the more the complications. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 3 1 Definitions 2 abdominal cavity: the abdomen is a hollow cavity, wherein lies the 3 organs such as stomach, interstines, duodenum, etc.,and blood blood vessels 4 such as aorta, vena cava, other arteries and veins. 5 aorta: the main blood vessel that carries blood from the heart to the rest of 6 the body. 7 anuerysm: dilatation and sac like formation of the blood vessel due to 8 weakening of its wall.aortic aneurysm means dilation of the aorta 9 aneurysm occurs from many causes but mainly due to aging of the 10 blood vessel. normally, close observation only is needed, but if the 11 size reaches a critical diameter e.g. 5 centimeters or greater or, if 12 symptoms such as back pain occurs surgical operaton must be done as 13 soon as possible. otherwise, the aorta may rupture. the result can be 14 fatal. because the blood flow is sluggish in the aneurysmal sac, there is 15 usually a blood clot, which needs to be removed. if not removed, the 16 blood clot will become dislodged and block the smaller blood 17 vessels. the result can be catastrophic. 18 artery:a blood vessel that carries blood from the heart to the rest of the 19 body. the aorta is the main artery. 20 arthritis: an inflammation of the joints. it usually occurs in the spine and 21 joints causing stiffness and pain. the x-rays of the spine with arthritis 22 shows spaces between the bones to be narrowed and formation of 23 abnormal bone. 24 bowels: intestines. there are two types-large and small. 25 duodenum: part of the intestine that lies between the stomach and the small 26 intestine. 27 EKG (electrocardiogram): an electrical wave pattern that records the 28 heart beat. normal heart beat ranges from 60 to 100 beats per minute. 29 the longer the surgery the more often the irregular heart beats are seen. 30 the normal pattern looks like this.... ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 4 1 PVC (premature ventricular contraction): an abnormal EKG 2 impulse that arises due to irritability of the heart. if untreated, can lead 3 to ventricular fibrillation. PVC is suppressed by the drug Lidocaine. 4 ventricular fibrillation: an irregular heart beat due to irritability of 5 the heart. it is very serious and is considered a terminal event unless 6 immediately corrected. 7 bradycardia: another irregular heart beat that results in slowing of the 8 heart. when this occurs the heart beat slows to about 50 beats per 9 minute or less. if untreated, it results in cardiac arrest where the heart 10 stops contraction. the drug Atropine usually reverses the slowing 11 of the heart. 12 blood pressure: a measurement of pressure or strain on the blood 13 vessel. a drop in blood pressure occurs from blood loss, prolonged 14 anesthesia, shift of body fluid contents during surgery or, injury to the 15 bowel contents, etc. the longer the surgery takes, the higher the risk of 16 the blood pressure dropping. normal saline (salt water) can 17 temporarily reverse the drop in blood pressure. Dopamine holds the 18 blood pressure up longer. a drop in blood pressure from blood loss 19 can be recovered only by replacement of blood. a drop in blood 20 pressure below 70 can lead to an irreversible state of shock. 21 iliac artery:a blood vessel that supplies blood to the leg. there are right 22 and left iliac arteries 23 mesenteric artery: a blood vessel that supplies the intestines. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 5 1 omentum: an extension of the peritoneum from the stomach and duodenum. 2 shaped like a large apron, it hangs down and covers the intestines. 3 ultrasound: a machine that looks at different internal organs by utilitzing 4 the relection of the sound wave. different organs reflect different 5 sound wave patterns. the patterns are then recorded and dipslayed as a 6 picture. 7 vascular surgeon: a surgeon who specializes in surgical operation of 8 blood vessels. 9 vein:a blood vessel that returns blood from the rest of the body to the heart 10 vena cava:a major vein that returns blood to the heart. superior vena 11 cava provides the blood return from the upper part of the body and 12 inferior vena cava carries the blood return from the lower part of the 13 body. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 6 1 the instruments and tools 2 scalpel ligation 3 forceps suture 4 scissors skin clip 5 clamps blood transfusion 6 retractors suction 7 surgeon's hand saline solution 8 sponges antibiotics 9 sterile drape dopamine 10 intestinal bag lidocane 11 skin antiseptic atropine 12 dacron graft heparin 13 do sponge count scrub 14 scalpel:a very sharp surgeon's knife used to cut the skin, fat muscles, etc 15 there are some cases where it is more advisable to use scissors. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 7 1 incisions must be made from the top to the bottom. up to five incisions 2 can be made for each layer. however, the best incision is usually a 3 clean and adequate single incision. 4 forceps: small clamps to stop the bleeding from small blood vessels 5 forceps are also used to lift up peritoneum and other linings. to release 6 the forceps, select the forceps icon and then click between the handle 7 of the forceps. the blood vessels that are clamped need to be tied and 8 ligated to permanently stop the bleeding. 9 there may be only 7 forceps on the screen at any one time. all forceps 10 must be removed before retracting and/or sizing the drape. 11 scissors: used to cut the peritoneum of other linings of the body which are 12 usually very close to vital organs where there is a danger of cutting the 13 organs underneath (this can occur when the scapel is used) of course 14 a niche or a hole in the linings has to be made first with the scapel. 15 usually, the peritoneum is lifted up away from the organ, with the 16 forceps and a niche is made with the scapel. the scissors are then 17 used. as in the scapel the cut has to made from above downwards. 18 the scissors are also used to cut the arteries or veins. 19 clamps: clamps are larger instruments needed to clamp large blood vessels 20 such as aorta and big arteries. 21 retractors: retractors are instruments needed to spread the incision area 22 wider to get a better view of the layers beneath and the organs inside. 23 just cutting the skin or the muscles will not expose the layers or organs 24 underneath. 25 surgeon's hand: hand is used to move or mobilize the organs, to 26 push duodenum away, to mobilize the aorta and to remove the blood 27 clot 28 sponge: sponges are used to wipe excess blood for a clean view when the 29 sponge changes its color i.e. soaked with blood, you must click the 30 sponge icon again to get another clean sponge. the surgeon must keep 31 track of the number of the sponges used. 32 drape:this is a sterile drape used to cover parts of the patient's body not 33 involved in the operation. hold down the button, while in the operating 34 field to size the exposed area in the drape. drape is used to prevent 35 contamination with germs during operation. 36 intestinal bag: after mobilizing the bowel and interstines to keep them out 37 of the way, it is better to keep them in the bag to prevent them from 38 falling back into the body cavity. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 8 1 antiseptic solution: normally, the patient's skin is covered with germs 2 and bacteria but the body cavity inside is totally free of germs. the 3 surgeon needs to clean up the skin thoroughly with the antiseptic 4 solution before entering into the body cavity. 5 dacron graft: the graft is made of a synthetic material, and is used to 6 replace the damaged part of the aorta. this creates a smooth functioning 7 lumen for the blood flow. click the cursor in the anterior half to fold the 8 anterior wall over for stitches. 9 sponge count: each time you use a sponge, you need to keep track of how 10 many sponges being used. many times a sponge is left behind in the 11 abdominal cavity. spones count is usually done before closing the 12 abdomen. click the icon-sponge count and answer the question. 13 ligation: the clamped bleeders need to be tied with the ligation before the 14 forceps are removed otherwise they will bleed again. to ligate (tie) the 15 vessel, click the ligation icon and then click the mouse at the bleeders 16 suture:the sutures are used to stitch the organs and linings of the abdomen 17 except the skin. 18 skin clip:the skin clipss are usually used to close the incision in the skin 19 blood:a drop in blood pressure from blood loss is controlled best by a blood 20 transfusion. there is a danger of reactions to blood transfusion 21 particularly if too many blood transfusions are given. therefore the ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 9 1 number of blood transfusion that can be given is limited to three. 2 suction: larger amount of blood is removed more quickly by suctioning. it 3 can only be used for bleeders inside the body. 4 saline solution: a salt solution that temporarily raises the blood 5 pressure. because the effect is usually transient, the number of saline 6 solutions that can be given is no more than three. 7 antibiotics: the operation involves openins of clean and delicate organs 8 antibiotics are usually given at the start of the operation. 9 dopamine: this medication is used to recover the drop in blood pressure 10 the effect lasts longer. in the game the dopamine can be used only 11 once. 12 lidocaine: the medication should be used only for the PVC's. using 13 lidocaine for other irregular heart beats can be dangerous. 14 heparin: heparin is a medicine used to prevent clotting of blood Heparin 15 should be used before cla mping the aorta. 16 scrub:the first thing a surgeon must do before any operation is to scrub i.e. 17 clean his hands thoroughly!! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 10 1 the layers of the abdomen 2 to reach to the aortic anuerysm we need to understand the layers of the 3 abdomen that we have to go through. 4 1.skin-every body knows what skin is 5 2.subcutaneous fat- a layer of fat 6 3.linea alba- a layer of fibres. 7 4.preperitoneal fat- a thin layer of fat stuck to the peritoneum that 8 needs to be scraped delicately-usually with a scapel-to get better access 9 to the peritoneum. the bowel underneath may be cut if undue pressure 10 is placed while scraping the preperitoneal fat 11 5.peritoneum- a smooth thin sheath that surrounds the organs such as 12 stomach,duodenum,intestines etc. imagine a balloon in which lies the 13 organs. 14 6.then comes the organs which you must move away to expose the posterior 15 part of the peritoneum 16 7.peritoneal fat- another thin layer of fat that needs to be scraped 17 away delicately with a scalpel. 18 8.posterior peritoneum- a thin sheath that covers the aorta. imagine a 19 posterior wall of the balloon 20 9.finally comes the aorta and the other blood vessels. the duodenum, a 21 part of the bowel also lies underneath the posterior peritoneum. it needs 22 to be moved away for a better view. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 11 1 amiga loading procedure: 2 to load the surgeon on the amiga first boot kickstart 1.2 followed by 3 workbench 1.2 the surgeon requires the 1.2 release to operate correctly use 4 of 1.1 may create problems during the game the game requires an amiga with a 5 minimum of 512k memory the game uses many hi-res color pictures which 6 accounts for its high memory usage the game must be booted from workbench 7 and no other applications may be opened On machines with extra memory, 8 however the game may be booted from either CLI or workbench and otherj 9 applications may be present. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 12 1 to play the game.... 2 one day mr.jones comes into your office for a checkup While examining 3 him you suspect an aortic aneurysm Since this can be a potentially fatal 4 problem requiring major surgery you must determine through a series of x-rays 5 and ultrascans whether an aneurysm actually exists or not Unfortunately other 6 diseases such as arthritis often produce similar symptoms If an operation is 7 needed there is a danger of the aneurysm bursting The result is fatal 8 after the decision hopefully the right one is made the operation begins This is 9 where your skill and experience as a vascular surgeon comes in... 10 first the surgical area need to be cleaned and free from infection The right 11 instrument must be used at each stage of operation A majority of the incisions 12 are midline and from the tope to bottom 13 the operation is delicate and care must be taken not to accidentally cut other 14 blood vessels and organs On the other hand the aorta and the branches need to 15 be clamped cut and ligated Of course the aneurysm has to be mobilized lifted 16 up first to be exposed The aneurysmal sac sometimes has a blood clot inside 17 which needs to be removed and heparin a blood thinner is usually given to 18 prevent new blood clot formation The new blood clot can becomes dislodged 19 and block the blood vessels in the legs The result can be detrimental 20 since the wall of the aorta is thin and baggy a graft must be placed to recreat a 21 smooth lumen Suturing the graft to the blood vessel wall has to be correct 22 After the graft is in place all the organs must be replaced and the walls closed 23 and sutured 24 throughtout the operation the EKG monitor and blood pressure need to be 25 watched closely Of course keeping track of the number of sponges forceps 26 and clamps that are used is also very important You do not want any of them to 27 be left behind!!! 28 nothing is more rewarding than performing a clean and successful operation 29 and saving a patient's life. 30 best of luck !!! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 13, PAGE 14 PICTURES OF X-RAYS AND ULTRASCAN ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 15 this is the actual step by step sequence necessary. only read this if you confess that you can never be a surgeon. even though the steps are explained, the explanation still does not prevent the complications that can occur. it is up to you to make sure it will never happen. >scrub >administer antibiotics >paint abdomen with antiseptic solution. >cover abdomen with sterile drape >incision of skin with scalpel. midline incision from above downward >wipe blood with sponges. clamping with forceps without wiping is easier, if bleeding is not excessive. >bleeders must be clamped with artery forceps then ligated >retract skin. remove all forceps first >incision of subcutaneous fat with scalpel. midline incision from above downward >retract subcutaneous fat >control bleeding as before >incision of linea alba. midline incision from above downward >retract linea alba >scrape preperitoneal fat with scalpel i.e.move the scalpel right and left for just a short distance >section of peritoneum wall at the top is elevated with forcep >elevated section is nicked with scalpel >full incision of peritoneum wall with scissors starting at nick >remove forcep >retract peritoneum >if small intestines were cut, clean with sponge and suture the cut >move small intestine out incision with hand >put intestines in intestinal bag >postperitoneal fat is scraped away with scalpel >section of posterior peritoneum wall at the top is elevated with forceps >elevated section is nicked with scalpel >full incision of peritoneum wall with scissors above downwards >remove forcep >retraction of posterior peritoneum wall >the duodenum is pushed up with the hand rubber tubes are looped around the aorta and the two common illiac arteries above and below the aneurysm >inject heparin >clamp the iliac arteries below the aneurysm first >clamp aorta neck above the aneurysm >clamp inferior mesenteric artery at it's root ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ PAGE 16 >the inferior mesenteric artery is cut and ligated near its root if you are having difficulty, try to click along its course near the root >remove clamp from inferior mesenteric >the aneurysm is incised. midline incision >clot is removed from anurysm by hand >the two lumbar arteries in the back of the aneurysm must be clamped and ligated. >the graft is inserted >the aorta neck is sutured. apply at least five stiches to the top edge of the graft neck Then click the needle on the bottom edge of the graft neck to fold it over finally apply five stiches to the now top edge >the two illiac branches are sutured the same way >the clamps are removed >unretract aneurysm . remove the retractor >suture aneurysm >unmobilized aneurysm with hand >unretract posterior peritoneum >sutured posterior peritoneum >the intestines are rplaced with hand >unretract preperitoneum >sutured preperitoneum >unretract linea alba >linea alba is sutured >skin is closed with skin clamps Operation is finished the original manual did not have the numbered lines so double check if the word don't work, the titles or headings are numbered 1, they may not supposed to be counted if so then just subtract 1 from the line numbers... -*{ Nemesis }*-