THE SURGEON README FIRST If you have a hard disk, "The Surgeon" can be made to load files much faster. To install "The Surgeon" on your hard drive, you must first run a program on the disk entitled "hd_install". To do this, simply open a cli window, 'cd' to the surgeon disk, and type "execute hd_install". This will copy the entire program, pictures, and sounds over to the hard drive. You will need about 500K free on the hard drive. Now, any time you wish to play the surgeon, you need only type 'assign surgeon: dh0:'. Do not boot the original disk anymore, the entire program is on your hard drive. You may wish to put the assign statement in your startup-sequence AMIGA LOADING PROCEDURE: To load "The Surgeon" on the Amiga, first boot Kickstart 1.2. Then place "The Surgeon" disk in drive 0. The program will boot automatically. For those with external drives, The Surgeon may be booted on drive 1 by clicking on the surgeon idon. "The Surgeon" requires the 1.2 release to operate correctly. Use of 1.1 may create problems during the game. The game requires a machine with at least 512K of memory. (i.e. a 256K machine will not be able to run "The Surgeon".) The game uses many high-res color pictures which accounts for its high memory usage. On a 512K machine, the game must be booted from Workbench, and no other applications should be opened. On machines with extra memory, however, the game may be booted from either CLI or Workbench, and other applications may be present. PROGRAM NOTES: If you choose to enter your name at the beginning of the program, you may do so by clicking in the empty requester box and typing in it. A default name will be given if you do not enter a name. Click "OK" to continue. FORCEPS/CLAMPS: There may be only 7 Forceps/Clamps on the screen at any one time. There is no need to have more than 7. Also, all Forceps/Clamps must be removed before retracting and/or sizing the dratp. The only exceptions to this rule is when retracting open the aorta, the 3 aorta clamps (neck, left iliac, and right iliac) may remain in place. Clamps are removed by clicking on the inside handle. HELP MODE: Pull down the menu and choose help. Help is in effect when the menu says "Help ON". When help is on, rectangles depicting valid cutting areas are displayed on the screen. Valid clamping areas are also displayed. DIFFICULTY LEVEL: There are 2 levels of difficulty: Resident, and Surgeon. These levels may be set on the main menu. In "Resident Mode", the user is informed of any irregular heart patterns, as well as dropping blood pressure. In "Surgeon Mode", the user must keep a watchful eye on the EKG as well as the blood pressure status. Also, complications occur more often in "Surgeon" mode. Both the Help mode and the difficulty level may be changed at any time during the program. (Or any time you feel lost!!) SOUND: When the game boots, sound will be on. If you do not wish to hear sound, choose the sound option on the menu. Sound may be toggled on or off. When cutting, always make the largest possible cut without going outside the operating window or the drape. The larger the incision, the more you will be able to see on the lower levels. If your incision is not large enough, you may not be able to operate properly on the lower levels. Also, all incisions must be made from the top down. Any attempt to cut up or to cut outside the acceptable areas will result in an "Unacceptable cut!!" message. After cutting the back wall of the Peritoneum, the game will pause while the program loads new images. This is normal. If after folding and stitching any 1 of the 3 graft ends you decide to unfold it, you will break any stitches placed. You must replace these with new stitches. Just as in an real operation, you can make many different kinds of mistakes. Some mistakes are minor, but others are deadly, such as failure to fully cover the patient's exposed area with anaseptic, or forgetting to administer the proper drugs at the proper time. Failure to pay close attention to shat you are doing can result in the death of your patient and the removal of your license!! Page 3 The "Surgeon" is not just an ordinary game. It is a simulation game!!. For those who wanted to be a surgeon, but never had a chance, and for the inspired young enthusiasts, the "SURGEON" offers the opportunity to live through the experience of a real surgeon. Even the terminologies used are authentic medical terminologies. It is an educational game!! "The Surgeon" allows you to learn the organs and layers of the human body while enjoying the fun of the game. You can also understand the procedure, and complications that are seen in a real life surgical operation. The steps involved in this operative procedure are as accurate as possible to a real operation of a disease called aneurysm. This can be a valuable assistance to medical students,physicians in training, or anyone who wishes to understand the human body and surgical procedures. Of course, the complications are dramitized. The "surgeon" is not forgiving (i.e. most mistakes are not tolerated). In reality, some of these mistakes can be corrected. And finally a game itself!! There are many traps and dangers like any other games. "The Surgeon" is a game of precision and skill. The whole operation depends upon the precision and accuracy of the surgical incisions. Many operations are delicate. A slight error and the results can be fatal. --------------------------------------------------------------------------------------- Page 4 What are the enemies of a surgeon? (1) Infection is the number one enemy for any surgical operation. Many times the operation is thought to be successful but only to find out later that the patient succumbs to an infection. (2) Bleeding, Cutting the wrong blood vessels can be dangerous and sometimes fatal. (3) The intestines are usually not clean. They contain with food and germs inside. Cutting the intestines by accident can contaminate the whole surgical procedure and can lead to infection. (4) The time taken to complete an operation is very critical. The longer the operation, the more the complications. ------------------------------------------------------------------------------------------ Page 5 DEFINITIONS ABDOMINAL CAVITY: The abdomen is a hollow cavity, wherein lies the organs such as stomach, instestines, duodenum, etc., and blood vessles such as aorta, vena cava, other arteries and veins. AORTA: The main blood vessel that carries blood from the heart to the rest of the body. ANEURYSM: Dilation and sac like formation of the blood vessel due to weakening of its wall. Aortic aneurysm means dilation of the aorta. Aneurysm occurs from many causes but mainly due to aging of the blood vessel. Normally, close observation only is needed, but if the size reaches a critical diameter e.g. 5 centimeters or greater or, if symptoms such as back pain occurs surgical operation must be done as soon as possible. Otherwise, the aorta may rupture. The result can be fatal. Because the blood flow is sluggish in the aneurysmal sac, there is usually a blood clot, which needs to be removed. If not removed, the blood clot will become dislodged and block the smaller blood vessels. The result can be catastrophic. ARTERY: A blood vessel that carries blood from the heart to the rest of the body. The aorta is the main artery. ARTHRITIS: An inflammation of the joints. It usually occurs in the spine and joints causing stiffness and pain. The X-rays of the spine with arthritis shows spaces between the bones to be narrowed and formation of abnormal bone. BOWELS: Intestines. There are two types - large and small. DUODENUM: Part of the intestine that lies between the stomach and the small intestine. EKG (ELECTROCARDIOGRAM): An electrical wave pattern that records the heart beat. Normal heat beat ranges from 60 to 100 beats per minute. The longer the surgery the more often the irregular heart beats are seen. The normal pattern looks like this..... ----/\-----/\-----/\--- ------------------------------------------------------------------------------------------- Page 6 PVC (PREMATURE VENTRICULAR CONTRACTION): An abnormal EKG impulse that arises due to irritability of the heart. If untreated, can lead to ventricular fibrillation. PVC is suppressed by the drug LIDOCAINE> --/\---\/---/\---\/---/\--- VENTRICULAR FIBRILLATION: An irregular heart beat due to irritability of the heart. It is very serious and is considered a terminal event unless immediately corrected. /\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\ BRADYCARDIA: Another irregular heart beat that results in slowing of the heart. When this occurs the heart beat slows to about 50 beats per minute or less. If untreated, it results in cardiac arrest where the heart stops contracting. The drug ATROPHINE usually reverses the slowing of the heart. -----/\------------------/\-----------------/\----- BLOOD PRESSURE: A measurement of pressure or strain on the blood vessel. A drop in blood pressure occurs from blood loss, prolonged anesthesia, shift of body fluid contents during surgery or, injury to the bowel contents, etc. The longer the surgery takes, the higher the risk of the blood pressure dropping. Normal saline (salt water) can temporarily reverse the drop in blood pressure. DOPAMINE holds the blood pressure up longer. A drop in blood pressure from blood loss can be recovered only by replacement of blood. A drop in blood pressure below 70 can lead to an irreversible state of shock. ILIAC ARTERY: A blood vessel that supplies blood to the leg. There are right and left iliac arteries. MESENTERIC ARTERY: A blood vessel that supplies the intestines. __________________________________________________________________________ Page 7 OMENTUM: An extension of the peritoneum from the stomach and duodenum. Shaped like a large apron, it hangs down and covers the intestines. ULTRASOUND: A machine that looks at different organs by utilizing the reflection of the sound wave. Different organs reflect different sound wave patterns. The patterns are then recorded and displayed as a picture. VEIN: A blood vessel that returns blood from the rest of the body to the heart. VENA CAVA: A major vein that returns blood to the heart. Superior vena cava provides the blood return from the upper part of the body and inferior vena cava carries the blood return from the lower part of the body. -------------------------------------------------------------------------------- Page 8 THE INSTRUMENTS AND TOOLS Scalpel Ligation Forceps Suture Scissors Skin clip Clamps Blood transfusion Retractors Suction Surgeon's Hand Saline solution Sponges Antibiotics Sterile Drape Dopomine Intestinal bag Lidocaine Skin Antiseptic Atropine Dacron graft Heparin Do sponge count Scrub SCALPEL: A very sharp surgeon's knife used to cut the skin, fat muscles, etc. There are some cases where it is more advisable to use scissors. ------------------------------------------------------------------------------------------- Page 9 Incisions must be made from the top to the bottom. Up to five incisions can be made for each layer. However, the best incision is usually a clean and adequate single incision. FORCEPS: Small clamps to stop the bleeding from small blood vessels. Forceps are also used to lift up peritoneum and other linings. To release the forceps, select the forceps icon and then click between the handles of the forceps. The blood vessels that are clamped need to be tied and ligated to permanently stop the bleeding. There may be only 7 forceps on the screen at any one time. All forceps must be removed before retracting and/or sizing the drape. SCISSORS: Used to cut the peritoneum or other linings of the body which are usually very close to vital organs where there is a danger of cutting the organs underneath (this can occur when the scapel is used). Of course, a niche or a hole in the linings has to be made first with the scapel. Usually, the peritoneum is lifted up away from the organ, with the forceps and a niche is made with the scapel. The scissors are then used. As in the scapel the cut has to be made from above downwards. The scissors are also used to cut the arteries or veins. CLAMPS: Clamps are larger instruments needed to clamp large blood vessels such as aorta or big arteries. RETRACTORS: Retractors are instruments needed to spread the incision area or to get a better view of the layers beneath and the organs inside. Just cutting the skin or the muscles will not expose the layers or organs underneath. SURGEON'S HAND: Hand is used to move or mobilize the organs, to push duodenum away, to mobilize the aorta and to remove the blood clot. SPONGE: Sponges are used to wipe excess blood for a clean view. When the sponge changes its color (i.e. soaked with blood), you must click the sponge icon again to get another clean sponge. The surgeon must keep track of the number of sponges used. DRAPE: This is a sterile drape used to cover parts of the patient's body not involved in the operation. Hold down the button, while in the operating field to "size" the exposed area in the drape. Drape is used to prevent contamination with germs during operation. INTESTINAL BAG: After mobilizing the bowel and intestines to keep them out of the way, it is better to keep them in the bag to prevent them from falling back into the body cavity ---------------------------------------------------------------------------------- Page 10 ANTISEPTIC SOLUTION: Normally, the patient's skin is covered with germs and bacteria but the body cavity inside is totally free of germs. The surgeon needs to clean up the skin throughly with the antiseptic solution before entering into the body cavity. DACRON GRAFT: The graft is made of a synthetic material, and is used to replace the damaged part of the aorta. This creates a smooth functioning lumen for the blood flow. Click the cursor in the anterior half to fold the anterior wall over for stitches. ! -------posterior half O!-------anterior half ! ! ! ! / \ / /\ \ anterior half-- O O \ / ! posterior half SPONGE COUNT: Each time you use a sponge, you need to keep track of how many sponges being used. Many times a sponge is left behind in the abdominal cavity. Sponge count is usually done before closing the abdomen. Click the icon-sponge count and answer the question. LIGATION: The clamped bleeders need to be tied with the ligation before the forceps are removed, otherwise they will bleed again. To ligate (tie) the vessel, click the ligation icon and then click the mouse at the bleeders. SUTURE: The sutures are used to stitch the organs and linings of the abdomen except the skin. SKIN CLIP: The skin clips are usually used to close the incision in the skin. BLOOD: A drop in blood pressure from blood loss is controlled best by a blood transfusion. There is a danger of reactions to blood transfusion, particularly if too many blood transfusions are given. Therefore the ------------------------------------------------------------------------------- Page 11 number of blood transfusion that can be given is limited to three. SUCTION: Larger amount of blood is removed more quickly by suctioning. It can only be used for bleeders inside the body. SALINE SOLUTION: A salt solution that temporarily raises the blood pressure. Because the effect is usually transient, the number of saline solutions that can be given is no more than three. ANTIBIOTICS: The operation involves opening of clean and delicate organs. Antibiotics are usually given at the start of the operation. DOPAMINE: This medication is used to recover the drop in blood pressure. The effect lasts longer. In the game, the dopamine can be used only once. LIDOCAINE: This medication should be used only for the PVC's. Using lidocaine for other irregular heart beats can be dangerous. ATROINE: The medication is used only for slow heart beat. Using atropine for other iular heart beat can be dangerous. HEPARIN: heparin is a medicine used to prrent clotting of blood. Heparin, should be used before clamping the aorta. SCRUB: The first thing a surgeon must do before any operation is to scrub i.e. clean his hands throughly!! ------------------------------------------------------------------------------------- Page 12 THE LAYERS OF THE ABDOMEN ----Skin ----Subcutaneous Fat ----Linea Alba ----Preperitoneal Fat ----Peritoneum ----Intestines ----Posterior Peritoneum ----Duodenum and Aorta To reach to the aortic aneurysm, we need to understand the layers of the abdomen that we have to go through. 1. SKIN - Every body knows what skin is. 2. SUBCUTANEOUS FAT - A layer of fat. 3. LINEA ALBA - A layer of fat. 4. PREPERITONEAL FAT - A thin layer of fat stuck to the peritoneum that needs to be scraped delicately-usually with a scapel-to get better access to the peritoneum. The bowel underneath may be cut if undue pressure is placed while scraping the preperitoneal fat. 5. PERITONEUM - A smooth thin sheath that surrounds the organs such as stomach, duodenum, intestines etc. Imagine a balloon in which lies the organs. 6. Then comes the organs which you must move away to expose the posterior part of the peritoneum. 7. PERITONEAL FAT - Another thin layer of fat that needs to be scraped away delicately with a scalpel. 8. POSTERIOR PERITONEUM - A thin sheath that covers the aorta. Imagine a posterior wall of the balloon. 9. Finally comes the AORTA and the other blood vessels. The DUODENUM, a part of the bowel also lies underneath the posterior peritoneum. It needs to be moved away for a better view. ---------------------------------------------------------------------------------- Page 13 AMIGA LOADING PROCEDURE: To load "The Surgeon" on the Amiga, first boot Kickstart 1.2, followed by Workbench 1.2 "The Surgeon" requires 1.2 release to operate correctly. Use of 1.1 may create problems during the game. The game requires an Amiga with a minimum of 512K memory. The game uses many Hi-res color pictures which accounts for its high memory usage. The game must be booted from Workbench, and no other applications may be opened. On machines with extra memory, however, the game may be booted from either CLI or Workbench, and other applications may be present. ---------------------------------------------------------------------------------- Page 14 TO PLAY THE GAME..... One day Mr. Jones comes into your office for a checkup. While examining him, you suspect an aortic aneurysm. Since this can be a portentially fatal problem requiring major surgery, you must determine through a series of x-rays and ultrascans whether an aneurysm actually exists or not. Unfortunately, other diseases such as arthritis often prduce similar symptoms. If an operation is performed unnecessarily, the dangers of complications exist as does the chance of the patient dying. On the other hand, if the surgery is not performed when needed, there is a danger of the aneurysm bursting. The result is fatal. After the decision (hopefully the right one) is made, the operation begins.This is where your skill and experience as a vascular surgeon comes in... First, the surgical area needs to be cleaned and free from infection. The right instrument must be used at each stage of operation.A majority of the incisions are midline and from top to bottom. The operation is delicate and care must be taken not to accidentally cut other blood vessels and organs. On the other hand, the aorta and the branches need to be clamped before the aneurysmal sac is opened. The mesenteric artery must be clamped, cut and ligated. Of course, the aneurysm has to be mobilized (lifted up) first to be exposed. The aneurysmal sac sometimes has a blood clot inside which needs to be removed and heparin (a blood thinner) is usually given to prevent new blood clot formation. The new blood clot can becomes dislodged and block the blood vessels in the legs. The result can be detrimental. Since the wall of the aorta is thin and baggy, a graft must be placed to recreate a smooth lumen. Suturing the graft to the blood vessel wall has to be correct.After the graft is in place, all the organs must be replaced and the walls closed and sutured. Throughout the operation, the EKG monitor and blood pressure need to be watched closely. Of course, keeping track of the number of sponges, forceps and clamps that are used is also very important. You do not want any of them to be left behind!!! Nothing is more rewarding than performing a clean and successful operation and saving a patient's life. BEST OF LUCK !!! ------------------------------------------------------------------------------ Page 15 ----Spine bone ----Space between two bones ----Hip bone X-Rays back of patient Gall Bladder-- -- Aorta Vena Cava-- ---Spine front of patient ULTRASONIC SCAN -------------------------------------------------------------------- Page 16 ---aorta neck duodenum-- Inferior vena cava-- mesenteric artery-- left right iliac iliac artery-- ---artery NORMAL AORTA ---aorta neck duodenum-- inferior vena cava-- mesenteric ---aneurysm artery--- left right iliac iliac artery-- --artery ANEURYSM ------------------------------------------------------------------------------- Page 17 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 explination 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. > Retrace peritoneum. > If small intestines were cut, clean with sponge and suture the cut. > Move small intestines 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 hand. > The anuerysm is mobilized with hand. (Rubber tubes are looped around the aorta, and the two common iliac 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 18 > 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) > Aneurysm is retracted open. > 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 stitches 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 stitches 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 > Unmobilize aneurysm with hand > Unretract posterior peritoneum > Sutured posterior peritoneum > The intestines are replaced with hand > Unretract preperitoneum > Suture preperitoneum > Unretract Linea alba > Linea alba is sutured > Skin is closed with skin clamps Operation is finished.