                             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

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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.

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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

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                    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.

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         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.

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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.