Operative Surgery Laparoscopic Surgery and Accessories
Operative Surgery Laparoscopic Surgery and Accessories Introduction:
Table of Contents
- Over a period of time, the number of operations an undergraduate is expected to know has become less and less.
- Today no MBBS doctor is supposed to do a surgical procedure because qualified surgeons are available even in a village
Read And Learn More: Surgery of Urology Notes
- Hence, I have discussed only some common surgical procedures that an undergraduate student is expected to know. Every operation has been discussed along a certain basic pattern.
- Students should study surgical anatomy before reading this chapter. Father of ancient surgery was an Indian, SushruthUnder the history of surgery, I have listed a few eminent surgeons who have contributed to surgery in the past.
- It is followed by some basic aspects of skin closure techniques and knotting principles. Suture materials have been discussed under the instruments section and surgical wound closure is discussed under appropriate surgeries.
- To give examples: the most common incision given is a midline incision. The most common surgeries done are appendicectomy hernioplasty, and students should study these surgeries in more detail.
- In this chapter common operations, laparoscopic surgeries and a few other accessories related to surgery are discussed.
History Of Surgery
Surgery emerged as a speciality in the late 19th century. There are many eminent surgeons who have contributed significantly in the development of surgery.
A few surgeons are uniquely associated with their work on a particular disease or speciality. There are numerous surgeons who have made distinct contributions in their respective specialities.
Some of the commonly known works and the surgeons associated with them are listed below.
Theodor Kocher (1841–1917): He was a student of Theodor Billroth and Bernhard von Langenbeck. He did extensive work on the thyroid and excised the thyroid for goitre in 1876.
Some of the contributions of Kocher are Kocher’s transverse incision for thyroid surgery, Kocherization of the duodenum, Kocher’s sign for Graves’ disease, Kocher’s forceps, He is known to be the father of thyroid surgery. He won the Nobel Prize in 1909.
Theodor Billroth: He was the first surgeon to remove a part of the oesophagus in 1872. In 1873, he performed the first complete excision of a larynx. He was the first surgeon to excise rectal cancer. He is credited with distinct eponymous works named after him that include Billroth’s 1 Operation, Billroth’s 2 Operation, Billroth’s Cord, etc. He is considered to be the father of abdominal surgery.
Halsted (1852–1922): He is well known for radical operations for breast cancer. He introduced surgical gloves to protect the hands of his scrub nurse, Caroline Hampton. He developed surgery for inguinal hernia. He also developed topical anaesthesia.
Sushrutha: Ancient history showed Sushruta (600 BC) to be the pioneer in plastic surgery and his work is described in Sushruta Samhita describes various surgical procedures and instruments uses famous surgery on ear lobe is believed to be a classical example of flap surgery used more than 2500 years ago in India is known to be “Father of Plastic Surgery”.
Skin Closure Techniques
- Good closure begins with a good incision
- The incision should be made with a scalpel at right angles to the skin.
- It should be made along the relaxed skin tension lines, this also results in minimal scarring on healing.
- The skin should be handled gently to avoid Devitalising the margins.
- The skin edges should be everted and approximated without tension.
- Circular incisions should be converted to elliptical incisions that are at least three times as long as wide, to allow the wound to heal without tension.
- Tension on the skin sutures can be minimised by using deep dermal and subdermal sutures.
- It is better to leave the suture line lax than using too much tension, as postoperative oedema will often take up any slack in the suture material. Using too much tension can compromise the vascularity of the edges.
The commonly used suture techniques for skin closure are:
- Simple interrupted sutures.
- Mattress sutures: These can be either vertical or horizontal mattress sutures. These produce an accurate approximation of wound edges.
- Subcuticular sutures: Good cosmetic outcomes.
- Other skin closure techniques include:
- Tissue glue which is composed of cyanoacrylate
- Skin adhesive strips, skin staples
Knotting Principles:
Tying a knot is one of the most fundamental skills that a surgeon has to acquire and perfect.
The important principles of knotting are:
- The knot should be tied firmly, not too tight, without exerting too much tension on the tissues.
- The knot should not slip. A few suture materials, such as proline, require additional throws to secure the knot.
- The knot should be compact and small to minimise the foreign material.
- The standard surgical knot is the reef knot, and additional throws are added for security. All knots should be squared.
- The suture should be cut appropriately after knotting leaving the thread at 1–2 mm length.
- In cases of continuous suture technique, an Aberdeen knot is used at the end.
- Abdominal incision closure has been given later.
Steps of Operative Surgery:
- Indications
- Contraindications
- Position of the patient
- Anaesthesia
- Preparation of parts
- Procedure
- Closure
- Postoperative management
- Postoperative complications
- Advice at discharge
Antiseptic Agents:
- Povidone-iodine
- Spirit 70%
- Savlon
Excision Of Swellings
Lipoma
1. Indications:
- Large size (cosmesis/patient’s wish)
- Recent rapid increase in size (sarcomatous change)
- Symptomatic naevo/neurolipomas
- Pressure symptoms based on site.
2. Contraindications:
Strictly speaking, there are no contraindications. Excision of lipoma is a simple procedure However, asymptomatic lipomas in a difficult location need not be excised However, small the surgery may be, safety is an important principle to be kept in mind.
3. Position of the Patient: Supine/lateral/prone depending upon the location.
4. Anaesthesia: If small, under LA; if large, regional anaesthesia or GA.
5. Preparation of the Parts: Povidone-iodine and spirit
6. Surgical Procedure:
- Incision: A linear incision over the summit of the swelling is placed and flaps are raised on both sides of the incision.
- Layers opened: Skin and some part of the subcutaneous tissue till the capsule of the swelling is encountered.
- Dissection: Using an artery forceps or a mosquito forceps (if there is a small swelling), a plane is created between the raised flaps and the capsule of the swelling. Pressure is applied at the base of the swelling to deliver out the lipom small vessel may be encountered as the base is being dissected that should be identified and cauterised or The specimen should be sent for histopathological evaluation.
7. Closure:
If a large cavity is created due to excision of swelling, the excised skin flaps can be refreshed and excess skin can be removed few interrupted Vicryl sutures can be placed to close the subcutaneous layer. The skin is closed with a 2.0 ethilon vertical mattress Sometimes, a drain may have to be kept in the cavity.
8. Postoperative Management: Nothing specific other than monitoring vitals and the operated area for bleeding. The majority of them can be done as daycare surgery.
9. Postoperative Complications:
- Infection, bleeding
- Injury to vital structures around
- Seroma formation, if a large cavity remains
10. Advice at Discharge:
Suture removal after 7–10 days, if non-absorbable sutures are used such as 3-0 silk. If absorbable sutures such as monocryl (3-0 Polyglactin) are used, there is no need to remove the sutures.
Sebaceous Cyst
1. Indications:
- Infection—results in abscess
- Complications such as Cock’s peculiar tumour, horn and calcification.
2. Contraindication: No specific contraindication.
3. Position of the Patient: Supine/lateral/prone depending upon the location.
4. Anaesthesia: Mostly Multiple cysts over the scalp and scrotum may require GA or regional anaesthesia.
5. Preparation of the Parts: Povidone-iodine and spirit.
6. Surgical Procedure:
- Incision: Elliptical incision around the summit of the swelling encircling the punctum.
- Layers opened:
- The incision should be superficial. Care should be taken not to cut open the cyst wall.
- The principle is to completely excise the cyst with its wall and the overlying punctum and a bit of the surrounding skin around the punctum.
- Dissection
- A plane is created between the skin and the cyst wall, carefully, preventing the opening of the cyst wall.
- An Allis forceps may be applied to the punctum and the elliptical skin to obtain traction. Flaps need to be raised gradually on either side of the incision and then deliver the cyst in toto.
- If the cyst wall opens up, the sebum is removed completely and an effort to remove all the cyst wall, piecemeal, is made.
7. Closure: Single-layer closure of the skin.
8. Postoperative Management: Nothing specific other than monitoring vitals and the operated area for bleeding. The majority of them can be done by daycare surgery. In infected cases, antibiotics are given.
9. Postoperative Complications
- Infection
- Recurrence, if the cyst wall is not completely removed.
10. Advice at Discharge: Suture removal after 7–10 days:
Neurofibroma
1. Indications:
- Cosmesis
- Symptoms of pain in pressure
- Pressure effects causing neurological deficits
- Sarcomatous changes
2. Contraindication: In von Recklinghausen’s disease, only symptomatic neurofibromas should be removed.
3. Position of the Patient: Supine/lateral/prone depending upon the location.
4. Anaesthesia: Mostly LA, sometimes GA.
5. Preparation of the Parts: Povidone-iodine and spirit.
6. Surgical Procedure:
- Incision: A linear incision over the summit of the swelling is placed and flaps are raised on both sides of the incision.
- Layers opened: Skin and some part of the subcutaneous tissue till the capsule of the swelling is encountered.
- Dissection: Using an artery forceps or a mosquito forceps (if there is a small swelling), a plane is created between the raised flaps and the capsule of the swelling. Pressure is applied at the base of the swelling to deliver out the neurofibromas should be taken so as not to injure the underlying nerve while dissecting.
7. Closure:
It can be closed in two layers, subcutaneous—vicryl, interrupted and skin 2-0/3–0 sutures.
8. Postoperative Management: Nothing specific other than monitoring vitals and the operated area for bleeding. The majority of them can be done as daycare surgery.
9. Postoperative Complications:
- Infection
- Injury to the nerve causes weakness and loss of sensations of the affected part.
- If partially left behind, recurrence and chance of sarcomatous changes.
10. Advice at Discharge: Suture removal after 7–10 days.
Surgery For Hydrocoele
This is done as a daycare surgery:
1. Indication: Vaginal hydrocoelHowever, infantile and funicular hydrocoeles are also treated surgically in the same manner.
2. Contraindication:
Secondary hydrocoele due to testicular tumours. They contain haemorrhagic fluid will be a big blunder to incise the scrotum mistaking it to be a vaginal hydrocoelSuspect testicular tumours if the hydrocoele is recent and lax, if the testis is felt separately and is hard in consistency or transillumination is negative.
3. Position of the Patient: Supine
4. Anaesthesia: SA or LA
5. Preparation of the Parts:
Savlon and spirit (iodine is better avoided because it can cause severe scrotal dermatitis and excoriation of skin, which can cause more discomfort to the patient than hydrocoele surgery).
6. Procedure:
Incision:
Hydrocoele is held tense by an assistant and a 5–6 cm incision (depending upon size) is made over the most prominent part of the swelling parallel to the median raphe of the scrotum.
Layers Opened:
- Skin
- Dartos
- External spermatic fascia
- Cremasteric fascia
- Internal spermatic fascia
- At this stage, the hydrocoele sac is visible and is delivered outside the incision.
Hydrocoele fluid is drained by using a trocar and a cannula opening is made in the tunica vaginalis sac and it is All fluid is drained out. Testis and epididymis are inspected for any pathology, e.g.
Craggy epididymis can be found in tuberculosis. Depending on the size of the hydrocoele and the thickness of the wall of the sac, two types of surgery can be done.
Small tunica vaginalis sac (TV sac): The redundant tunica vaginalis is plicated by interrupted sutures. The sac gets crumpled up and surrounds the testis. This is called the Lord’s plication. The advantage of this operation is minimal dissection, hence no complications.
Sac is large and thick or multilocular hydrocoele: Partial excision of the hydrocoele sac is done leaving a margin of 1–2 cm. After obtaining hemostasis, the eversion of the sac is here cut edge of the sac is everted and sutured behind the testis. This is called Jaboulay’s operation. By eversion of the sac, the secreting surface of the testis becomes anterior and secretions are absorbed by subcutaneous lymphatics.
Sharma and Jhawer’s technique: In this, minimum dissection of the sac is done to separate it from the surrounding region. This will avoid complications such as bleeding.
7. Closure:
- In the vast majority of cases, if perfect hemostasis is obtained, draining the cavity is not required tube drain can be kept in the scrotum, if required When kept brought out separately by making a stab incision and anchoring to the scrotal skin by white thread.
- Subcutaneous layer by using absorbable sutures such as vicryl sutures.
- Skin—interrupted absorbable sutures (polyglactin— rapid vicryl). Silk is avoided for skin closure over the scrotum as the black colour of the silk is not seen clearly over the dark pigmented skin of the scrotum, making stitch removal difficult.
- Scrotal support is given to reduce oedema.
8. Postoperative Management:
- NPO for 6 hours followed by a soft diet.
- Prophylactic antibiotics are given. Postoperative antibiotics are not required.
- Use Monocryl which is a synthetic, absorbable suture—No need to remove sutures.
9. Postoperative Complications:
- Haematoma: If it is large and increasing, the wound should be reopened urgently and bleeders have to be ligateIt may be due to injury to the testicular artery, vein or pampiniform plexus of veins. Scrotal oedema can occur which resolves within 2–3 days.
- Wound infection can result in discharging pus.
- Testis can undergo necrosis. Such cases are treated with orchidectomy.
- Injury to the spermatic cord.
10. Advice at Discharge: Normal activity within 1 or 2 days.
Incision And Drainage (I And D)
1. Indication: Pyogenic abscess, pyaemic abscesses.
2. Contraindication: Cold abscess.
3. Position of the Patient: Supine, prone or lateral depending upon the site of an abscess.
4. Anaesthesia
- Regional anaesthesia or GA is preferred because the abscess is multiloculated and infiltration of lignocaine into the abscess cavity does not act because of the acidic pH of the pus.
- However, a superficial abscess which is pointing can be managed without GA.
5. Preparation of the Parts: Iodine and spirit.
6. Procedure:
- A stab incision is made over the most prominent part of the swelling where the skin is red, thinned out and pointed.
- Pus that is drained is sent for culture and sensitivity.
- A sinus forceps or finger is introduced within the abscess cavity and all the loculi are broken. When fresh blood oozes out, it indicates completion of the procedure
- The cavity is irrigated with antiseptic agents such as iodine solution. It is followed by irrigation with normal saline.
- If the cavity is large, it is packed with roller gauze soaked in iodine and it is removed after 24–48 hours. Packing helps in controlling the bleeding and keeps the abscess cavity open. By 7–10 days, the cavity collapses, granulation tissue fills up the cavity and healing takes place.
Hilton’s method of drainage: When an abscess is located over a major vessel, as in the axilla or neck, do not make a stab incision. An incision is made on the skin and subcutaneous tissue and sinus forceps are introduced Later, it is treated like the treatment of an abscess. This method is followed to avoid injury to major vessels and nerves. It is also indicated in parotid abscess to avoid damage to facial nervous forceps because it is a blunt-tipped instrument without a lock system so opening and closing the blades are easy. It has a few serrations at the tip so that, if necessary, a biopsy of the wall can be taken.
7. Closure:
An abscess should not be closed, as it contains pus, and bacteria (see also breast abscess drainage). However, in breast abscess, once all loculi are broken and after a thorough wash, the wound is closed with sutures, a drain is kept in the dependent position and brought out by a separate incision.
8. Postoperative Management:
- Antibiotics
- Control of diabetes (if the patient is diabetic)
- Regular dressings of the wound with antiseptic agents.
9. Postoperative Complications:
- During the process of breaking the loculi, vessels underneath may be injured causing haematoma which requires drainagOtherwise, there are no specific complications.
- Injury to vessels or nerves can occur, if basic principles of drainage of an abscess are not followed.
10. Advice at Discharge:
Control of diabetes (if present).
Incision And Drainage Of Breast Abscess
1. Indication: Breast abscess
2. Contraindication: However, ultrasound-guided aspiration of breast abscesses should be done first, especially in unilocular breast abscesses.
3. Position of the Patient: Supine
4. Anaesthesia: GA
5. Preparation: Iodine and spirit
6. Procedure:
About 3 to 4 cm semicircular incision is made over the swelling where there is maximum tenderness. It is drained just like pyogenic abscess. Another stab incision is made in the dependent position and tube drain is brought out through this incision. Corrugated drains are not used often now.
7. Closure:
- If the infection is very severe, do not close the incision.
- Otherwise, the main wound is sutured and the tube drain is brought down at the dependent position. Once the drainage is minimal, the drain is removed.
8. Postoperative Management:
- NPO for about 6 hours
- The antibiotic of choice is cloxacillin 500 mg 6th hourly because the common organism is Staphylococcus aureus.
- It may take 7–15 days for complete healing.
- One should not wait for fluctuation to develop in a breast abscess. If pain and tenderness do not subside by 48 hours, the breast abscess is incised Otherwise, breast tissue gets damaged.
9. Postoperative Complications: Haematoma needs evacuation.
10. Advice at Discharge: Lactating women should clean the nipple after every breastfed and keep it clean.
Circumcision
Circumcision refers to the removal of the preputial skin:
1. Indications:
- Ritual: Religious
- Phimosis
2. Contraindication: Hypospadias
3. Position of the Patient: Supine
4. Anaesthesia:
- In children—GA
- In adults—LA
5. Preparation of the Parts: Savlon and spirit
6. Procedure:
In Adults:
- The skin of the tip of the penis is held in two places by using artery forceps, prepuce is separated from the glans and is slit up in the mid-dorsal line to a point a little beyond the middle of the glans.
- Preputial layers are trimmed away in a line parallel to the coronal ventral surface, the frenular artery needs to be ligated by using a figure of 8 stitch. Two layers of prepuce are united by interrupted fine chromic vicryl sutures/vicryl. Dressings are applied.
In Children:
- Prepuce is held by two artery forceps and gentle traction is applied small artery clamp is applied distal to the glans and skin distal to the clamp is removed.
- Once the clamp is removed, bleeding points are identified and ligated.
- Two layers of prepuce are approximated by using 5–0 vicryl.
7. Closure: Two layers of prepuce by using vicryl sutures.
8. Postoperative Management:
- Sedatives and analgesics
- Antibiotics
- Removal of sutures is very painful. Hence, do not use nonabsorbable sutures.
9. Postoperative Complications:
- Injury to the glans penis can occur when there are extensive adhesions between the prepuce and glans. It needs suturing.
- Haematoma: Due to injury to the corpora cavernosa or due to the bleeding from cut edges.
- Tension at the suture line, if too much skin is removed. This may cause a painful erection at a later date.
10. Advice at Discharge:
This surgery in adults is done on an outpatient basis. Patients are discharged within a few hours. Hence, patients are advised to report, if there is bleeding and also not to wet the area for 2–3 days.
Venesection Or Cut Down
1. Indications:
- Shock: Hypovolaemic, haemorrhagic, burns, etc.
- When peripheral veins are not visible due to shock, burns or massive haemorrhage, an incision is made in the anatomical sites of the vein. The vein is identified, isolated and cannulated for transfusion of fluids. This procedure is called venesection or cut down.
2. Contraindication: None
3. Position of the Patient: Supine
4. Anaesthesia: Local infiltration by using 2% lignocaine 3–5 ml.
5. Preparation: Iodine and spirit
6. Procedure:
A cephalic vein cut down is the most popular and an ideal procedure transverse incision of about 5 cm is made in the deltopectoral groove cephalic vein is isolated and the distal end of the vein is ligated so that venous blood does not leak. A nick is made in the vein, through which a sufficient-sized cannula (infant feeding tube can be used) is introduced silk ligature is applied above, just tight enough to hold the cannula in place flow of venous blood in the cannula indicates that it is inside the vein. The cannula is advanced further for about 10–15 cm. It is connected to IV line containing fluid.
Venesection Or Cut Down Precautions:
- Take care not to inject air bubbles. Remove all air bubbles present in the drip set also to avoid air embolism.
- The upper ligature should not be tight. It may obstruct the flow of fluids.
- Strict antiseptic principles must be followed to avoid septicaemia.
Other Veins Selected for Cut-Down:
- A basilic vein in the arm.
- Cubital vein at the elbow.
- A long saphenous vein in the leg. Veins in the leg, as far as possible, should be avoided to prevent deep vein thrombosis.
7. Closure: Skin—interrupted silk
8. Postoperative Management:
- Care of wound by dressing
- To avoid air bubbles in the drip set
9. Postoperative Complications:
- Infection, chills, rigours and septicaemia
- Air embolism
10. Advice at Discharge: Nil
Advantages of Cephalic Vein Cut-Down:
- Reliable vein and is easy to do.
- If a cannula is advanced into the right heart, CVP can be measured
- The mobility of the patient is not restricted.
- Substances which cannot be given in a peripheral vein, such as 50% dextrose, can be given without risk of thrombosis of the vein, for hyperalimentation purposes.
Vasectomy
Division and removal of a part of the vas deferens is vasectomy:
1. Indications
- Family planning
- To prevent epididymal-orchitis after prostatectomy. (Nowadays not routinely done.)
2. Contraindications:
- Relative: Tuberculosis epididymo-orchitis. The incision may result in a nonhealing sinus. Hence, control of tuberculosis is done first followed by vasectomy.
- Absolute: Suspicion of testicular malignancy.
3. Position of the Patient:
- Supine
- Cleaning and draping: Parts are cleaned and draped. Vas is palpated.
4. Anaesthesia: Local anaesthesia using 3–5 ml of 2% lignocaine.
5. Preparation of the Parts:
- Savlon and spirit
- Iodine is better avoided.
6. Procedure:
Feeling the Vas Deferens:
After cleaning and draping, the vas is felt, at the root of the scrotum between the index finger and thumb feels like a corLignocaine is infiltrated and wait for 1–2 minutes for lignocaine to act.
Vasectomy Incision:
An incision of 2–4 cm is made in the root of the scrotum and it is deepened through layers of the scrotum. An ‘Allis forceps’ is introduced within the incision and the spermatic cord is During this step, fingers of the other hand help in guiding/locating/stabilising the core coverings of the cord are incised
Vasectomy Precautions:
- Do not damage testicular vessels.
- Vas is separate as confirmed by its white colour, and it feels like a cord.
- Division of vas by three clamp method (Fig. 70.10).
- Vas is cut in two places A and B so that a piece of vas is removed, which can be sent for histopathology to confirm that it is vas.
- Since a piece of the vas is removed, a reunion of the cut ends will not occur.
- The two cut ends of the vas are doubly ligated by using silk.
7. Closure: The skin is closed by absorbable one or two sutures so that removal not required.
8. Postoperative Management:
- Rest for a few hours
- Antibiotics and analgesics
9. Postoperative Complications:
- Injury to the vessels, results in a large haematoma.
- Infection
- Testicular atrophy can occur a few years later. It is due to immunological reaction rather than disuse atrophy.
10. Advice at Discharge:
To use other methods of family planning for two months while having sexual intercourse, as some sperm may be present in the distal end of the vas and seminal vesicle.
No Scalpel Vasectomy:
- It is a novel technique to do vasectomy through one single puncture which does not require any suturing. It is less traumatic than conventional vasectomy and shortens recovery time.
- The procedure is done with LA.
- A special instrument is used to puncture the scrotum and grasp the vas deferens. Vas is then cut and through the same puncture, the other side is also operated.
Tracheostomy
An opening made in the trachea is tracheostomy:
1. Indications:
- Emergency:
- Choking of the larynx due to dentures, foreign bodies, fish bones, etc.
- Stridor due to diphtheria, carcinoma larynx and bilateral recurrent laryngeal nerve paralysis after thyroidectomy.
- Elective
- Coma
- Tetanus
- Barbiturate poisoning
- Head injuries
- Prolonged respiratory failure
2. Contraindications:
- Absence of any specific indication. In patients with anaplastic carcinoma of the thyroid presenting with stridor due to infiltration of growth into the trachea, it may not be possible to do a tracheostomy or an attempt to do tracheostomy may result in the growth fungating through the incision (which is best avoided). In such patients, endotracheal intubation is done, if possible If not possible, no other intervention is done.
- In very urgent cases, needle cricothyrotomy can be done.
3. Position of the Patient: Supine with the extension of the neck and head by keeping a sandbag or a pillow under the shoulders.
4. Anaesthesia: Local infiltration anaesthesia
5. Preparation of the Parts: Iodine and spirit
6. Procedure:
- Incision: A transverse curved incision for about 3–4 cm is made at the level of the 2nd tracheal ring.
- Dissection: Skin, subcutaneous tissue and deep fascia are inciseIsthmus of the thyroid is separated.
- Procedure: A transverse cut is made in the 2nd tracheal cartilage, its edge is held with Allis forceps and a small cuff of cartilage is removed hook’ can be used to stabilise the trachea (found more useful in children).
- A suitable-sized tracheostomy tube is introduced within.
- The cuff of the tracheostomy tube is inflated by using 2–5 ml of air and is held in place by passing a tape around the neck.
- Confirm that the tube is in the trachea, not in the subcutaneous plane.
- Confirm air entry on both sides of the lung.
7. Closure: A few interrupted skin sutures by the side of the tracheostomy tube and dressing is applied.
8. Postoperative Management:
- Suction of tracheostomy tube, regular dressing
- Humidification of air
- Check for air entry
9. Postoperative Complications:
- Wound infection
- Air leakage
- Improper air entry
- Cricoid stenosis (high tracheostomy).
Closure of Tracheostomy:
- Once the patient improves and is able to take care of his own airway, the tracheostomy tube is blocked Observe for 24–48 hours.
- If there is no respiratory distress, the cuff is deflated and the tube is removed few skin sutures can be put or dressing is applied automatically.
10. Advice at Discharge:
- Tracheostomy done after laryngectomy is permanent. Patients should learn to use metal tracheostomy, cleaning the tubes, et
- The inner tube should be removed, cleaned and replaced in cases of respiratory distress.
Thyroidectomy
1. Indications:
- All goitres with symptoms—MNG, toxic goitre, colloid goitre and malignant goitre.
- In all cases of toxic goitres, patients have to be optimised into normothyroid or euthyroid before surgery to avoid dangerous complications such as a thyrotoxic storm or crisis.
2. Contraindications: Asymptomatic goitre, Hashimoto’s thyroiditis, anaplastic carcinoma thyroid.
3. Position of the Patient:
- Supine with an extended neck by keeping a sandbag under the shoulders.
- The head end of the patient is elevated to about 30° to reduce venous congestion. This position is called the anti-Trendelenburg position.
4. Anaesthesia: GA.
5. Preparation of the Parts: Iodine and spirit
6. Procedure:
ThyroidectomyIncision:
- 6–8 cm collar neck incision (Kocher’s incision) or crease incision is given about 2 cm above the suprasternal notch along the natural crease of the neck or just above it.
Thyroidectomy Layers Opened:
- Skin, platysma, subcutaneous tissue in the line of incision. Small bleeders are coagulated.
- Deep fascia is incised vertically.
- Strap muscles are separated (can be cut in very large goitres). Sternothyroid, thyrohyoid and sternohyoid muscles. Most superficial muscles are sternohyoi
- Pretracheal fascia is incised.
- Thyroid gland is mobilised by using blunt dissection.
- Assess the entire gland to know whether it is a solitary nodule or multinodular goitre.
- One of the lobes is mobilised by dividing middle thyroid vein (single, short, thin, vein).
- Then, upper pole is dissecteThis pedicle contains superior thyroid artery and veins. They are ligated and divided in between. Please apply double ligature proximally. Let the dissection be close to the gland.
- Dissection and retraction of the upper pole of the right thyroid lobe laterally will open up a space called cricothyroid space of Reeves. Here we can find the external branch of the superior laryngeal nerv
- Upper pole should be ligated as close to the gland as possible to avoid damage to external laryngeal nerv
- Inferior thyroid artery used to be ligated1 well away from the glanIt has a horizontal coursIt is thick and pulsatilNowadays branches of inferior thyroid artery rather than the main artery are ligateThis will avoid injury to recurrent laryngeal nerve and it will prevent hypoparathyroidism also. Multiple veins, present in the lower pole, are ligated and divided.
- Isthmus is separated from trachea, both above and below.
- In subtotal thyroidectomy, the entire isthmus, parts of the right and left lobes are removed in flush with tracheal surface, leaving behind tissue in the tracheoesophageal groove to protect recurrent laryngeal nerve and parathyroid glanCut edges of thyroid gland are sutured by using vicryl sutures. In total thyroidectomy, almost entire gland is removed.
Precautions:
- Any structure directly entering the gland is unlikely to be RLN and hence, can safely be divided.
- Always identify the RLN. That is the best way to avoid injury to the nervRecurrent laryngeal nerve enters the thyrohyoid membrane, after running a vertical course, in the tracheoesophageal groove.
7. Closure:
- A suction drain is kept in the thyroid bed.
- Deep fascia is sutured with 2-0 vicry
- Subcutaneous fat—vicryl
- Skin—interrupted silk/subcuticular sutures or clips
- A bandage is applied.
8. Postoperative Management:
- NPO for 6–8 hours followed by liquid diet.
- Antibiotics are not necessary.
- Head end must be elevated to reduce oedema of the wound.
- In toxic goitres, propranolol must be continued after surgery and slowly tapered over a week.
- Blood transfusion depending upon blood loss.
- Drain removal after 2–3 days (once it stops draining).
- Suture removal after 4–5 days.
9. Postoperative Complications:
- Haemorrhage: Tension haematomReactionary haemorrhage is due to slipping of ligature due to coughing, hypertension, etIf it is alarming, deep fascial sutures have to be opened, haematoma drained and haemostasis has to be achieved.
- Thyrotoxic crisis in patients with toxic goitre
- Tracheomalacia—resulting in stridor
- Recurrent laryngeal nerve paralysis
- Hypothyroidism
- Hypoparathyroidism
- Wound infection
10. Advice at Discharge:
This depends on the type of indication for thyroid surgery, e.g. those who undergo subtotal thyroidectomy for thyrotoxicosis have to be closely followed for recurrent thyrotoxicosis or hypothyroidism. If calcium levels are low, it has to be supplemented.
Different Types of Thyroidectomy:
Question 1. What is Zuckerkandl’s tubercle?
Answer:
- Zuckerkandl’s tubercle is a pyramidal extension of the thyroid gland, located at the most posterior side of each lobe.
- The structure is important in thyroid surgery as it is closely related to the recurrent laryngeal nerve, the inferior thyroid artery, Berry’s ligament and the parathyroid glands.
- It is also important to remove this in toto while doing thyroidectomy for malignancies.
Amputations
Definitions/Terminologies of Amputation:
- End bearing: Weight is taken by the body.
- Non-end bearing: Here weight is taken by the joint.
- Guillotine amputation: Here no flaps are raised, all the tissues are divided at the same level and the stump is kept open.
- Formal amputation: In this case depending upon the indications and the decisions taken by the surgeon, amputation is done with closure of the stump.
Amputation Indications
- The vitality of the part is destroyed by injury or disease— dead lim
- The life of patient is threatened by spread of a local condition—deadly limExamples: Gas gangrene, extensive melanoma.
- Patients may be better served by an artificial limb because of deformity or paralysis—a deformed limb. In such cases, better to amputate and fit in an artificial limb.
- Dying limb—acutely ischaemic limb, late presentation.
Optimum Levels of Amputation:
- The level of amputation depends not only upon the extent of disease but also function desired in the remaining stump.
- This differs markedly in the upper and lower limbs.
Ideal Stump:
- Should have ideal length for proper fitting of prosthesis. Examples: Below knee: 8 to 12 cm from tibial tuberosity, above knee: 23 cm from greater trochanter and above and below elbow: 20 cm stump.
- Should be conical and rounded.
- Should not be tender.
- Should have adequate muscle padding so that its movements are adequate.
- Should have adequate blood supply so that it heals with primary intention in the postoperative perio
- Should have a thin scar which should not interfere with prosthetic function.
- Should not have any redundant soft tissue hanging.
- Skin and scar should not be adhered to the underlying tissue.
Amputation Incisions:
Depending upon the site of the level of amputation and keeping in mind the blood supply of the part, different types of incision are given. They are as follows:
- Racquet incision: This is used in amputation for digits or toes.
- Elliptical or oval incision is given for metatarsal amputations.
- Circular incision is given especially in Guillotine amputation.
- U-shaped incisions: These are given to raise flaps—anterior and posterior flaps as in below knee or above kneBy convention equal flaps are used for above knee and a long posterior and short anterior flaps are used for below knee amputation. This is because, vascularity of the posterior flap is good below the knee due to bulky muscles with good blood supply when compared to the thin, muscle less anterior flap (see ten commandments).
Amputations In Leg
Skeleton of foot: To have a better understanding of amputations kindly study.
- One of the common indications for lower limb amputations is diabetic ulcer/gangrene foot. Various types and various levels of amputations are done with the main aim is to conserve as much as possible.
However, when the limb is a useless limb, a below knee or an above knee amputation is done depending upon the seriousness of the problem.
1. Ray amputation: It is amputation of the toe with head of metatarsal or metacarpals.
2. Transmetatarsal/metacarpal amputation: It is called Gilles’ amputation. When multiple toes are involved with gangrene as in vasculitis syndromes or in diabetic patients, amputation is done through metatarsal bones—proximal to the neck, distal to the basLong volar flap is created and sutured to the dorsal skin.
3. Lisfranc’s amputation (tarsometatarsal amputation): Tarsometatarsal articulations are called Lisfranc joint. The bones forming these are the first, second, and third cuneiforms, and the cuboid, which articulate with the bases of the metatarsal bones. The bones are connected by dorsal, plantar, and interosseous ligaments. These ligaments have to be divideA long volar flap is usePatient needs a surgical boot.
4. Chopart’s amputation: Francis Chopart first described disarticulation through midtarsal joint. It is midtarsal amputation. Disarticulation of the foot is completed through talonavicular joint and through calcaneocuboid joint. Thus, Chopart amputation removes the forefoot and midfoot, saving talus and calcaneus. Tibialis anterior muscle is sutured to the drilled talus bon
- Contraindication: Ischaemic feet as in atherosclerosis.
- Disadvantages: It is a very unstable amputation, because most of the tendons supporting the foot will be removeThus, it will go for equinus and must usually be fitted with a prosthesis that extends up to the patellar tendon level.
5. Syme’s amputation:
- The tibia and fibula are divided at or immediately above the level of ankle joint and their ends are covered with a single flap obtained from heel.
- The end of the stump is at a height of about 6–8 cm from the ground.
- 50% of people will be able to walk on the stump without prosthesis.
- It is of value in patients who do not have access to modern artificial limbs.
- Pirgroff’s modification of Syme’s amputatio retains a small portion of calcaneum in the flap obtained from heel.
- Heel flap is supplied by medial and lateral calcaneal vessels, both are branches of posterior tibial artery.
- Those who will not be able to walk after this amputation, can be fitted with elephant boot.
6. Below knee amputation:
- It is the operation of choice when it is not possible to preserve the foot or heel.
- The ideal length of the tibial stump is 14 cm.
- Minimum length required to fit an artificial leg is 8 cm. Stump shorter than this tends to slip out of the socket of an artificial limb.
- The stump is covered by creating long posterior flap.
- This is the amputation commonly done in patients who are in severe sepsis involving the leg with uncontrolled diabetes and life is in danger.
- All the rules mentioned above in ten commandments are followed here such as division of the nerve, flap vascularity, reduction of bulky muscles and the anterior scar, thus prosthesis will not cause discomfort while walking.
- Advantages of below knee amputation include greater range of movements without limp and without support.
- This amputation is also called Burgess amputation.
- The POP cast should be put to prevent contractures.
7. Amputations through thigh:
- The ideal length is 25–30 cm as measured from tip of trochanter.
- It is done when it is not possible to save at least 8 cm of tibia as in some cases of diabetes or spreading infections of the leg and when muscles involved are not bleeding at surgery.
- When this amputation is done in children, as much length as possible should be preserved (growing epiphysis of femur is at lower end).
- Unlike, below knee amputation, equal flaps are raised—anterior and posterior.
- Any length less than 10 cm of femur will not help. In such cases, hip disarticulation is done.
- In peripheral arterial occlusive disease, an attempt is made first by raising below knee flaps. If edges of the skin flaps do not bleed, better to go ahead with above knee flaps because vascularity of above knee flaps are better. Above knee amputation stump healing is better than below knee.
- Disadvantages of this amputation are difficult rehabilitation (not easy), prosthesis fitting is not good, invariably patient needs one more support.
8. Hip disarticulation:
- When it is not possible to get minimum of 10 cm length of stump of the femur, hip disarticulation is donThis situation can occur in trauma or malignancies to get a wide clearanc
- Examples: Sarcomas or in cases of malignant melanomas.
- Usually a single posterior flap is raised—Solcum’s approach.
- Anterior approach can also be used (2nd option)—Boyd’s approach.
9. Hindquarter amputation:
- In this amputation—one side of pelvis with innominate bone, pubis, muscles and vessels are removeHence, it is called hemipelvectomy today.
- Indications are trauma and tumour (malignancy).
- In the original description, common iliac artery used to be ligateHowever, now the branches of external and internal iliac artery are ligated.
- A large posterior flap based on superior gluteal artery is used.
- Variations in this amputation are: Extended hemipelvectomy with removal of posterior part of the sacrum.
- Limb preserving hemipelvectomy: It is called internal hemipelvectomy.
Upper Limb Amputations
General Principles
- Conserve as much tissue as possible.
- Skin closure should not be under tension.
- Soft tissue cover over bony stump is desirable.
- Otherwise, the painful adherent scar will result.
- Amputation through the middle or terminal phalanx is preferred to disarticulation at interphalangeal joints since attachment of flexor tendons is thereby preserved.
- Every effort should be made to preserve as much of the thumb.
Amputation Through the Forearm And Upper Arm
- Ideal stump is 16–20 cm measured from olecranon.
- Stump less than 8 cm is useless for transmitting movement to an artificial elbow joint.
- A stump measuring 20 cm from acromion is ideal for fitting prosthesis.
Krukenberg’s amputation: In this amputation, a gap is created between radius and ulna like a claw. It helps in holding objects.
Interscapulothoracic Amputation (Forequarter Amputation):
- Indications are for malignancy involving axial skeleton such as sarcomSepsis involving the upper limb is another indication such as gas gangrene.
- It is a very radical mutilating operation, hence all possible limb saving attempts should be done first.
- Entire upper limb with scapula and lateral 2/3rds of the clavicle with all the muscles attached to it are removed.
Complications following Amputation:
1. Wound infection: Especially it is common in amputations done for diabetic gangrene cases. Stitches may have to be opened to release pus followed by secondary suturing at a later date.
2. Flap necrosis: It is a common complication because of several reasons, important one being decreased blood supply to the limb either due to arterial occlusive disease or due to diabetes. Necrotic skin and subcutaneous tissues should be removed followed by secondary suturing at a later datHence, blood supply of the flap has to be kept in mind when raising the flaps.
3. Stump ulcers are common in the initial stages of wearing artificial limbs.
4. Contracture: If the artificial limb is not fitted, the stump will develop flexion contracture.
5. Amputation neuroma: This is an end neuromThe cut end of the nerve is entrapped in the scar tissue and gives rise to pain. To avoid this, nerve end is pulled and cut so that after division of the nerve, the end gets retracte
6. Phantom limb: A phantom limb is the sensation that a missing limb is attached to the body. Approximately 60 to 80% of individuals with an amputation experience phantom sensations in their amputated limb, and the majority of the sensations are painful. It is probably due to presence of a severe pain at the amputated site before surgery and the corresponding site in the brain has registered this sensation.
Abdominal Incisions
Amputation Introduction:
Incisions are given to approach an organ for removal or repair.
The most important 3 criteria when incisions are given are:
- Accessibility
- Extensibility
- Safety.
Many examples can be given for each one of these however, one example for each one of the above 3 criteria has been given below.
1. Accessibility:
- When an incision is given, if a surgeon should be able to reach the organ without many difficulties.
- A classical example is: a McBurney incision given at the site of maximum tenderness. As soon as the peritoneum is opened, you can see the appendix. (More details later). The subcostal incision on the left side gives direct access to the spleen for splenectomy.
2. Extensibility:
- Surprises are known inside the abdomen and hence it is called as Pandora’s box. When a upper midline incision is given for perforation peritonitis, if a lesion is identified in the lower abdomen, incision can be extended easily till midline incisions are popular and have this great advantag
- If a surgeon has given McBurney incision for suspected appendicitis, after opening the abdomen he finds that the appendix is normal but it is a case of perforation of Meckel’s diverticulitis, often the McBurney incision has to be closed and midline incision given to facilitate removal of Meckel’s diverticulum.
3. Safety:
- Midline incisions are safe during laparotomy because no important nerve or artery is present in the midlin If precautions are not properly taken in paramedian incisions, traction on the nerves while retracting the muscles can result in nerve injuries. This may weaken the rectus abdominis muscle.
Amputation Various Incisions:
- Midline incisions, paramedian incisions (not done nowadays), McBurney grid iron incision, Kocher’s subcostal incision, Pfannenstiel incision are commonly used incisions.
- Left abdominothoracic—an oblique incision above the umbilicus crossing along the 7th or 8th intercostal space for removing large spleens or exposure of lower oesophagus and right midline incision with right posterolateral thoracotomy through 5th intercostal space for oesophageal cancer are other incisions used.
- Details are not required for undergraduate students. Those of you are interested can refer to operative surgery books. Midline incision is given here, the rest have been covered along with respective operative surgery.
Midline Incisions
Upper and lower midline and mid-midline are commonly used incisions which give exposure to every viscus in the abdominal cavity. They are described her Other incisions and approach have been given later with the procedure of surgery.
- To understand the formation of rectus sheath and linea alba which forms basis of midline incisions.
- Upper midline incision: Layers opened are—skin, subcutaneous fat, linea alba, preperitoneal fat and peritoneum. Closure is done mainly by taking good bites from the linea alba and skin.
- Peritoneum heals with proliferation of mesothelial cells. A few surgeons also take bites through peritoneum with absorbable sutures such as 2–0 polyglactin, linea alba with 2–0 prolene/PDS and skin with silk sutures.
- Lower midline incision: Layers opened are—skin, subcutaneous fat, linea albHowever, linea alba is not present in the lower part of lower abdomen below linea semilunaris linThen preperitoneal fat and peritoneum are inciseClosure is done mainly by taking good bites from the linea alba and skin.
- Closure is similar to that of upper midline incision
Appendicectomy
This is the most commonly done emergency surgery by general surgeons all over the worlToday almost every appendicectomy is done by laparoscopic approach. Basic concepts of laparoscopy have been given in the later pages.
1. Indications
- Acute appendicitis—emergency appendicectomy
- Recurrent appendicitis—elective appendicectomy
2. Contraindications: Appendicular mass
3. Position of the Patient: Supine
4. Anaesthesia of the Parts: This surgery can be done either under GA or regional anaesthesia (spinal or epidural).
5. Preparation: Parts are cleaned with iodine and spirit, from the level of umbilicus above to the upper part of thigh below.
6. Procedure:
Appendicectomy Incision:
1. McBurney’s grid-iron incision is the most popular incision. It is at right angles to spino-umbilical line placed at McBurney’s point. It is about 6–8 cm in length.
2. Lanz incision is a curved transverse incision, placed at the McBurney’s point. Cosmetically, it is a better incision.
3. Midline incision is made when diagnosis is in doubt as a part of exploratory laparotomy. This is also preferred in females where there is a gynaecological pathology such as ovarian cyst which may be the cause of right iliac fossa pain.
Layers Opened:
- Skin
- Two layers of subcutaneous tissue—superficial fatty (Camper’s), deep membranous (Scarpa’s). (C: comes first, S: later). There is no deep fascia in the abdomen.
- External oblique aponeurosis is seen running downwards and medially. It is incised in the direction of its fibres.
- Internal and transverse abdominal muscles are split (grid iron—right angle to each other).
- The peritoneum is incised.
Features of Acute Appendicitis at Operation:
- Inflamed, turgid appendix—send pus/inflammatory exudate for culture/sensitivity
- Pus in the right iliac fossa
- The presence of omentum in the right iliac fossa
- Black or green appendix (gangrenous)
- Faecolith
Identification of the Appendix
- Trace taenia coli. They will lead to the base of appendix (all roads lead to Rome).
- Identify round structure—caecum and then look for appendix
- Often it is retrocaecal. In such cases, you need to mobilise right paracolic space by incising posterior peritoneal reflection.
- When you are tracing taenia coli, if you are not able to identify the appendix, it means most probably you are tracing taenia coli of the sigmoid colon.
- It may be subhepatic in cases of undescended caecum.
Surgical Procedure:
- Appendix is gently held at mesoappendix by using Babcock’s forceps and blood vessels in the mesoappendix are divideThese include appendicular artery, branch of ileocolic artery (accessory appendicular artery of Seshachalam, is a branch of posterior caecal artery). Once appendix is freed up to the base (caecum), a purse string suture is applied all round appendix, taking bites from caecum, using 2–0 atraumatic silk.
- Appendix is crushed at base and is held 1 cm above the crush. A tight silk ligature is applied at the crushed site and appendix is cut in between. Stump is cleaned with spirit, invaginated and purse string is tighteneThis is called burial of the stump. Perfect haemostasis is obtained.
- Look for Meckel’s diverticulum and if found make a note of this in the operative surgery notes.
7. Closure:
- Peritoneum—continuous 2–0 vicryl
- Split muscles—sutured together by a few interrupted sutures using 2–0 vicryl
- External oblique is sutured with silk
- Subcutaneous fat is sutured with vicryl
- Skin with interrupted silk.
- Peritoneal wash with saline is given and the area is dried with mop.
- Tube drain is not kept routinely unless there is gangrenous appendicitis or a lot of pus in the peritoneal cavity.
8. Postoperative Management:
- RT aspiration is only in cases of peritonitis or persistent vomiting. Otherwise, nasogastric aspiration is not required. 4 fluids 2.5 litres/day for one or two days.
- Oral fluids are allowed within 6–8 hours or very next day once abdomen is soft and bowel sounds are heard.
- Appropriate antibiotics to cover gram-positive, gramnegative and anaerobic organisms.
- Suture removal by 7–10 days.
9. Complications after Appendicectomy:
Postoperative fever can be due to various factors. Thrombophlebitis, urinary tract infection and IV fluids are common causes. In the absence of these, wound infection, intraperitoneal abscess secondary to gangrenous appendicitis, may have to be considere
- Change of antibiotics according to culture and sensitivity reports of urine, pus and blood help in treating postoperative fever.
- Elderly patients may have a pre-existing pulmonary diseas Respiratory tract infection also has to be considered.
Wound infection: It is the most common complication after appendicectomy. When in doubt open stitches and let out the pus.
An intra-abdominal abscess needs drainage
Faecal fistula—causes
- Gangrene spreading into caecum
- Persistent infection
- Carcinoma caecum (elderly patients)
- Ileocaecal tuberculosis
- Crohn’s disease (uncommon in India)
- Actinomycosis (rare)¹.
Septicaemia, portal pyaemia, gram-negative shock in late cases of peritonitis due to perforated appendicitis are uncommon but dangerous complications.
- Mortality of appendicular perforation and peritonitis is around 2%.
10. Advice at Discharge: To report, if any fever or discharge from the wound.
Bassini’S Herniorrhaphy
- This means herniotomy and approximation of conjoined tendon to inguinal ligament to strengthen the posterior wall of the inguinal canal. With availability of the mesh, this surgery is not routinely used. However, in strangulated hernias, after resection of the bowel, one cannot repair with mesh. Bassini’s herniorrhaphy is still a good option.
- In large, long-standing hernias and in sliding hernias, especially in elderly patients, it is better to catheterise their bladder before surgery for two reasons. Firstly, to avoid injury to the urinary bladder and secondly, they invariably develop retention of urine in the postoperative period.
1. Indication: Inguinal hernias. Strangulated hernias.
2. Contraindication (Relative): Severe cardiopulmonary insufficiency
3. Position of the Patient: Supine
4. Anaesthesia: Regional anaesthesia or local anaesthesia can be preferred in high-risk patients.
5. Preparation of the Parts: Like that for appendicectomy
6. Procedure:
Incision:
- A 4–6 cm incision is made parallel to the inguinal ligament at the level of the deep ring in the medial two-thirds of the inguinal ligament.
Layers Opened:
- Skin
- Two layers of superficial fascia
- The external oblique is incised in the line of direction of fibres, till the external ring is slit open.
- Thin cremasteric box—thin covering is opened
- Identification of the sac—glistening white colour.
- Isolate the cord from the sac—by blunt and sharp dissection. The cord is held separately by using cord-holding forceps.
- Mobilisation of the sac: The sac is mobilised up to the deep ring. Mobilisation is complete when inferior epigastric artery pulsations and extraperitoneal pad of fat are seen.
- Opening of the sac: The sac is opened and the contents are examined.
- Reduction of contents: The contents are reduced into the peritoneal cavity carefully by using blunt forceps. Check carefully in bleeding from omental vessels.
- Twist the sac so that the contents get reduced completely so as to avoid injury to the contents of the sac later while excising the sac.
- Transfixation ligature:
- It means suture ligature is passed through the sac:
- It is applied as high as possible at the neck of sac and it is tightened Excision of the sac
- Exicion of the sac:
- As a rule, after excision, the ligated end of the sac should disappear from the operative field (which means it will go into the peritoneal cavity). After excision, see the excised sac and see whether omentum or intestine has been injured to this stage, it is called herniotomy.
- The conjoined tendon above is approximated to the inguinal ligament below by using nonabsorbable suture such as nylon or However, in strangulated hernias, PDS (polydioxanone)—a synthetic but absorbable sutures can be useIt gets absorbed between 130 and 180 days.
- Nonabsorbable suture is used so that its strength remains for a long time repair is called Bassini’s herniorrhaphy
7. Closure:
- The external oblique is sutured with chromic catgut or silk.
- Subcutaneous fat with absorbable catgut suture.
- Skin with silk.
Precautions:
- The ilioinguinal nerve should not be caught in ligature.
- Conjoined muscles should not be strangulated.
- There should not be any tension in the suture lines.
8. Postoperative Management:
- NPO for 6–8 hours, oral fluids and soft diet later.
- Analgesics.
- Prophylactic antibiotics, 1 dose is given 6 hours before surgery.
- Scrotal support, if the dissection is more (complete hernia).
- Suture removal after 7–10 days.
9. Postoperative Complications:
- Immediate: Haematoma due to injury to the pampiniform plexus of veins or improper haemostasis. It may need re-exploration.
- Wound infection may result in discharging pus which is the cause of postoperative fever. Infection is the chief cause of recurrence.
- Severe periostitis pubis (to avoid this nowadays, the repair is not done by taking bites through pubic bone). X-ray of the bone may have to be taken for diagnosis.
- It is managed by analgesics and in intractable cases, injection of corticosteroids locally may reduce the pain.
4. Nerve entrapment causing pain:
10. Advice at Discharge:
- Not to strain or lift heavyweights (e.g. bucketful of water) or to carry load on the shoulders for 3 months.
- If there is any precipitating cause such as chronic cough or difficulty in passing urine, etthey have to be treated first. Otherwise, hernia will recur once again.
Desarda Repair
- Principle of Desarda repair: In normal individuals, the transversus abdominis aponeurosis (aponeurotic extensions) in the posterior wall is strong and elastic because of its aponeurotic nature and healthy muscles around keep it physiologically dynamic to give lifelong protection against hernia formation. This transversus abdominis aponeurosis is absent or deficient in hernia patients.
- The Desarda repair technique uses an undetached strip of nearby external oblique aponeurosis to replace those absent aponeurotic extensions. This gives again a strong and elastic posterior wall. Another fact noted in hernia patients is the weakness of the muscle arch muscles that fail to keep the posterior wall physiologically dynamiIn Desarda repair, the strip is continuous with its original strong muscle and this nearby external oblique muscle gives additional strength to the muscle arch muscles to keep this posterior wall physiologically dynamic.
Anaesthesia: Surgery can be done under local or spinal anaesthesia.
Surgery:
- Skin and fascia are incised through a regular oblique inguinal incision to expose the external oblique aponeurosis.
- The external oblique is cut in line with the upper crux of the superficial ring, which leaves the thinned-out portion in the lower leaf so a good strip can be taken from the upper leaThe external oblique, which is thinned out as a result of ageing or long-standing large hernias, can also be used for repair if it is able to hold the sutures.
- Upper and lower leaves are cleared from surrounding tissue by proper undermining.
- Sac is excised protecting the ilio-inguinal nerve.
- The upper leaf of the external oblique aponeurosis (EOA) is sutured to the inguinal ligament from the pubic tubercle to the internal ring using PDSII no. 1 or ‘0’ (Monofilament Polydioxanone violet, Ethicon) continuous sutures. The first suture is taken in the anterior rectus sheath part of the external oblique aponeurosis upper leaf above and the medial most part of the inguinal ligament below near the pubic tubercle The last suture is taken so as to sufficiently narrow the new internal ring without constricting the spermatic cord by pushing the cord against the arching muscle fibres to its maximum extent. Here, we are creating a new internal ring in the EOA with the help of the strip while suturing the strip’s lower border to the inguinal ligament. The original internal ring becomes defunct. Lateral pushing of the spermatic cord against the arching muscle fibers to maximum extent is necessary while this suturing is don Each suture is passed first through the inguinal ligament and then the external oblique upper lea Needle bites are taken as close to the border of the EOA as possible (about 1 2 mm). The index finger of the left hand is used to protect the iliac vessels and retract the cord structures laterally while taking lateral sutures.
- A splitting incision is made in this sutured upper leaf, partially separating a strip of 1–2 cm width but never more than 2 cm. Normally 1.5 cm wide strip is sufficient for most of the patients. This splitting incision is extended medially up to the pubic symphysis and laterally 2–3 cm beyond the internal ring. The medial insertion and lateral continuation of this strip is kept intact.
- A strip of the external oblique is now available, the lower border of which is already sutured to the inguinal ligament. The upper free border of the strip is now sutured to the internal oblique or conjoined muscle lying close to it with PDSII no. 1 or ‘0’ (Monofilament Polydioxanone violet, Ethicon) continuous sutures throughout its length.
- The aponeurotic portion of the internal oblique muscle is used for suturing to this strip wherever and whenever possible; otherwise, it is not essential for the success of the operation. This will result in the strip of the external oblique being placed behind the cord to form a new posterior wall of inguinal canal.
- At this stage the patient is asked to cough and the increased tension (physiological tension) on the strip exerted by the external oblique to support the weakened internal oblique and transversus abdominis is clearly visible.
- The spermatic cord is placed in the inguinal canal and the lower leaf of the external oblique is sutured to the newly formed upper leaf of the external oblique in front of the cord, as usual, again using PDSII no.1 or ‘0’ (Monofilament Polydioxanone violet, Ethicon) continuous sutures.
- The undermining of the newly formed upper leaf on both of its surfaces facilitate its approximation to the lower leaThe first stitch is taken between the lateral corner of the splitting incision and lower leaf of the external obliquThis is followed by closure of the superficial fascia and the skin as usual. This repair is written by ProDesarda and has been edited by authors.
Further Reading:
- A short handbook of Desarda Repair for inguinal herniapublished on electronic and print media—Author: Pro (Dr) Desarda Mohan Phulchand (MB, MS, FICS, FICA), Professor, Department of Surgery and Chief of the hernia centre, Poona Hospital and Research Centre, Pune (India).
Open Cholecystectomy
In the vast majority of the cases, gallbladder is removed by laparoscopic routDetails have been given in the gallbladder chapter. In this chapter, we will be studying gallbladder removed through open method—after doing a laparotomy.
Open Cholecystectomy Definition
Removal of the diseased gallbladder by a laparotomy.
1. Indications:
Laparoscopic cholecystectomy is now the gold standard for cholecystectomy. However, the role of open cholecystectomy is present when laparoscopic cholecystectomy fails due to extensive adhesions, excessive bleeding, CBD injury, impacted gallbladder, et (complications of laparoscopic cholecystectomy)
- Symptomatic gallstones
- Acute/chronic/acalculous cholecystitis
- Empyema gallbladder
- Mucocoele of gallbladder
- Asymptomatic gallstones—patients with high risk such as diabetes, haemolytic anaemias such as sickle cell anaemias and hereditary spherocytosis.
2. Contraindications:
- Unfit for surgery
- Chronically debilitated patients
3. Position of the Patient:
Supine: In laparoscopic cholecystectomy, the head end is elevated and a slight tilt is given to left side so that omentum and bowel fall away from the operating field.
4. Anaesthesia: GA
5. Preparation of the Parts: From level of nipple to lower abdomen, parts are cleaned with povidone-iodine and spirit.
6. Surgical Procedure:
- Incision: Right subcostal incision (Kocher’s incision) preferred/right paramedian.
- Layers opened: Skin, subcutaneous tissue, muscles (external oblique, internal oblique and transversus abdominis), preperitoneal fat and peritoneum.
- Dissection:
- After opening the abdomen, colon and stomach are retracted away.
- Fundus of the gallbladder is held with a sponge holding forceps and retracted.
- Assistant retracts the liver using a Deaver retractor.
- Calot’s triangle is identifieThe cystic artery is identified, doubly ligated with 2.0 silk sutures and cut.
- Cystic duct is now identified, skeletonised, doubly ligated with silk or vicryl sutures and cut.
- The gallbladder is dissected off the gallbladder fossa using electrocautery and haemostasis is achieved.
- Rarely, fundus first approach: When Calot’s triangle anatomy is not clear due to inflammation and adhesions, the dissection is started from the fundus and proceeded towards the cystic duct which is ligated in the end.
- Intra-abdominal drain is placed.
7. Closure:
- Inner muscle layer—No. 1 prolene continuous interlocking.
- Outer muscle (2nd layer of muscles)—same suture.
- Subcutaneous layer—2.0 vicryl interrupted.
- Skin—2.0 ethilon/silk vertical mattress.
8. Postoperative Management:
- Nil per oral till patient passes flatus
- To continue antibiotics in diabetic patients
- Watch for hypotension (bleeding), tachycardia, abdominal distension, pain (bile leak).
- If drain is kept, it is usually removed within 2–3 days.
- To avoid having oily foods
9. Postoperative Complications:
- Infections and subphrenic abscess
- Bleeding from cystic artery
- Injury to CBD or hepatic duct—presents with jaundice in the postoperative period.
- Bile leak and fistulae
- Biliary stricture formations (late)
- Injuries to colon, duodenum and mesentery.
10. Advice at Discharge:
- Not to strain for 30 days—to prevent incisional hernia developing later.
- To avoid fatty food
- To report if jaundice develops (CBD injury or retained stone in CBD) or fever which may be due to subphrenic collection. (It can be treated with ultrasoundguided aspiration.)
Vagotomy Gastrojejunostomy (GJ)
Vagotomy GJ, as it was called, is a procedure that was commonly performed by surgeons until the invention of proton pump inhibitors increasing awareness and advent of upper GI endoscopies.
Earlier, the incidence and complications of peptic ulcer were high and the commonly performed surgery for peptic ulcer was vagotomy GJ. It was also done for the complications of gastric ulcers such as gastric outlet obstruction due to strictures. However, nowadays this procedure is rarely done.
1. Indications:
- Symptomatic peptic ulcer disease not responding to medical management.
- Complications of gastric ulcers such as stenosis and bleeding.
2. Contraindication:
- Vagotomy needs a bit of dissection near the hiatus.
- Hence, a risk of mediastinitis is present, if vagotomy is done in cases of perforation. Hence, a simple closure of perforation is done in emergency situations.
3. Position of the Patient: Supine
4. Anaesthesia: GA
5. Preparation of the Parts: From level of nipple to lower abdomen, parts are cleaned with povidone iodine and spirit.
6. Surgical Procedurez:
- Incision—upper midline
- Layers opened—skin, subcutaneous tissue, linea alba, preperitoneal fat, peritoneum.
- Dissection
- After opening the abdomen, the pathology in the stomach or duodenum is noted and confirmed.
- Gentle traction is given at the anterior stomach wall. The stomach is delivered out of the wound.
- The oesophagus is palpated with the in situ nasogastric tube between the thumb and the fingers.
- The peritoneum over the overlying distal oesophagus is incised and the oesophagus is gently mobiliseThe oesophagus is encircled with a Penrose drain and lifted to visualise the anterior vagus. Once identified, it is cut after ligating or applying clips. A 2 cm portion of the nerve may be excised.
- Similarly, the posterior nerve is found as a taut band between the right crus of diaphragm and the oesophagus which is identified and cut.
- The duodenogastric junction is identified after lifting the transverse colon and its mesentery.
- The first loop of the jejunum (1 foot from the DJ) is taken and gastrojejunal anastomosis is performed in 2 layers—inner full thickness continuous suture with 3.0 vicryl and outer seromuscular interrupted sutures with 3–0 silk. The loop is usually taken posterior to the transverse colon through a surgically made rent in the transverse mesocolon (retrocolic) and is isoperistaltic.
7. Closure:
- Peritoneum along with linea alba is sutured with no 1 prolene or loop ethilon continuous interlocking suture.
- Subcutaneous —2.0 vicryl interrupted sutures.
- Skin —2.0 ethilon vertical mattress sutures.
8. Postoperative Management:
- NPO for 2 days till patient passes flatus—indication that there is no anastomotic leak. Ryle’s tube is removed, then followed by clear fluids by mouth for 2–3 days followed by soft diet.
- Suture removal by 7–10 days
- Fluid and electrolytes have to be checked in the postoperative period.
9. Postoperative Complications:
- Postvagotomy diarrhoea, due to denervation of the gut.
- Afferent loop obstruction/stomal oedema.
- Gallstone formation due to denervation of gallbladder.
- Stomal ulcers due to bile reflux
- Bile reflux gastritis
10. Advice at Discharge:
- To avoid large heavy meals
- Small frequent feeds better
- Avoid spicy and oily foods
- All details about complications of vagotomy and GJ
Intestinal Resection And Anastomosis
Intestinal Resection And Anastomosis Introduction:
Bowel anastomosis involves the surgical join between two intestinal segments. Bowel anastomosis is usually done to restore bowel continuity as part of surgery for diseased bowel or to bypass unresectable bowel. It may be accomplished either by handsewn technique or by the use of stapler devices. It has been stated that the key to a successful anastomosis is the accurate union of two viable bowel ends with complete avoidance of tension. If anastomosis is not successful, complications can be very, very disastrous.
Physiology of Anastomosis Healing:
The healing process at the anastomotic site is divided into three phases:
1. Inflammatory phase: The inflammatory phase lasts for the first 4 days during which the anastomosis is dependent on the mechanical strength provided by the sutures or staples. Hence, any AL occurring during the first two postoperative days is likely to be due to technical factors.
2. Proliferative or fibroplasia phase: The second phase of proliferation starts from the 5th postoperative day and lasts up to the 14th postoperative day. There is an increased collagen deposition during this phase to give tensile strength to the anastomosis
3. Reparative or remodelling phase: The last phase of remodelling occurs up to 1 year after the surgery. During this phase, rebuilding of the intestinal wall layers occurs at the anastomotic site.
Blood Flow and Anastomosis:
The blood supply to the bowel is derived from the mesentery with vessels travelling on either side of the bowel wall to reach antimesenteric border. Hence, the anastomosis is centred on the antimesenteric border when possible.
Instruments used for Intestinal Anastomosis:
- Straight artery forceps for stay sutures, scissors to cut the intestines and forceps to hold the edge of the intestines to see carefully the layers taken while suturing.
- Curved small artery forceps for catching the bleeders followed by coagulation.
- Babcock’s forceps for holding the intestines together, thus getting ready for anastomosis.
- Moynihan’s occlusion clamps—straight and curved— are applied to occlude the lumen so that contents of the intestine are not spilled over and also to control bleeding.
Suture Materials Used:
Intestines: Inner absorbable such as 2–0 polyglactin (Vicryl) and outer 2–0 atraumatic silk.
Handsewn Anastomosis:
- It can be performed in a single layer or double layer fashion. Single layer anastomosis usually employs full thickness bites of the bowel wall.
- In a doublelayered anastomosis, the inner layer consists of full thickness bites whilst the outer layer consists of seromuscular bites. There is no proven advantage regarding the type of suture material use
- The ideal suture material should provide good tensile strength during the anastomotic site healing process with minimal local tissue reaction. Commonly used suture materials are 2–0 vicryl continuous for inner mucosal sutures and 2–0 interrupted for outer seromuscular layer.
Stapler Anastomosis:
Stapler anastomosis drastically reduces the operating time, however, it requires the surgeon to be familiar with the stapling devices. They are usually not preferred, if the bowel is edematous due to high risk of anastomotic leak. There are different types of surgical staplers available for resection and anastomosis of bowel.
- Transverse anastomosis (TA) staplers: They are noncutting staplers that require the specimen to be cut with scalpel or scissors after laying down the stapler rows.
- Linear staplers: They are popularly known as gastrointestinal anastomosis (GIA) staplers. They have a cutting mechanism for transection of bowel in addition to laying down stapler rows. These types are very commonly used for bowel resection and anastomosis in small and large bowel
- End-to-end anastomosis (EEA) staplers: These are circular cutting staplers that place several rows of staples. These are used in coloerectal and oesophagogastric anastomosis.
- Staplers are available in different staple line lengths and configurations. The cartridges are colour coded to indicate the height of the staples which are used based on the thickness of bowel being anastomosed.
Type of Anastomosis:
Anastomosis between two bowel segments can be created in various ways.
- End-to-end: This is performed when two bowel segments are of roughly equal caliber. In case of an unequal caliber, a Cheatle slit on the smaller caliber bowel will aid in anastomosis.
- End-to-side: This type is preferred when one bowel segment is wider than the other.
- Side-to-side: This type of anastomosis is carried out on the antimesenteric side of two bowel segments. It is the most commonly employed type of anastomosis.
Complications of Bowel Anastomosis:
- Anastomotic leak
- Bleeding
- Wound infection
- Prolonged ileus
- Anastomotic stricture
Anastomotic Leak:
Anastomotic leak is the most dreaded complication following intestinal resection and leads to high morbidity and mortality. Anastomotic leaks are usually identifiable by postoperative day 3–5. It occurs due to the breakdown or insufficiency at the anastomotic line and is defined as the leak of luminal contents from a surgical join between two hollow viscera which is identified.
- Clinically by extravasation of bowel content through drain/wound.
- Radiologically by the presence of collection adjacent to anastomosis.
- Intraoperatively during re-exploration.
Risk factors for anastomotic leak: They may be categorized into patient factors and technical factors. Some of the risk factors like smoking and consumption of alcohol may be modifiable.
Risk factors for anastomotic leak:
Colectomy
Right Hemicolectomy:
Colectomy Indications:
- Carcinoma of the caecum or ascending colon
- Tumours of appendix
- Extended right hemicolectomy for carcinoma of hepatic flexure and proximal 1/3rd transverse colon and for closed loop obstruction in carcinoma of the transverse colon.
- Modified right hemicolectomy for tuberculosis, Crohn’s disease involving terminal ileum.
Structures Removed:
- Terminal 5–10 cm of ileum
- Caecum
- Ascending colon
- Proximal 1/3rd of transverse colon with hepatic flexure.
- Extended right hemicolectomy—all the above structures with the proximal two-thirds of the transverse colon.
- Modified right hemicolectomy—all the above structures with variable length of hepatic flexure or proximal transverse colon preserved.
Vessels Ligated:
- Ileocolic vessels
- Right colic vessels
- Right branch of middle colic vessels
- Ileal vessels are ligated last
Surgical Techniques:
1. Laparotomy through midline/right paramedian incision.
2. Exploration of the abdomen for liver deposits, peritoneal deposits, ascites and other synchronous lesions.
3. Assessment of the tumour for site, extent, mobility, serosal involvement and local extension.
4. Mobilisation of the right colon done by incising along the avascular lateral peritoneal fold or white line of Toldt and rotating the caecum and the ascending colon anteriorly and medially.
5. Retroperitoneum is entered through the incision and dissection carried up towards the third and fourth part of duodenum.
6. Retroperitoneal structures encountered during dissection are the right kidney with ureter, right gonadal vessels and duodenum. Care must be taken to avoid injury to these structures.
7. Turnbull’s technique or no touch isolation technique—early ligation of the vessels before manipulation of the tumour should be followed to prevent dissemination of the tumour cells during handling.
8. Ileocolic, right colic, right branch of middle colic and lastly ileal vessels are isolated, ligated and divide Ileocolic and right colic vessels are ligated at the origin to include all the associated lymph nodes.
9. Ileum is transected at 5–10 cm from the ileocaecal junction and transverse colon at the junction of the proximal 1/3rd and distal 2/3rds. This is followed by an ileotransverse colon anastomosis.
10. Abdominal wall is closed in layers.
Left Hemicolectomy
Left Hemicolectomy Indications:
- Carcinoma of the descending colon
- Carcinoma of the splenic flexure
- High-risk polyps
Structures Removed:
Carcinoma of the Descending Colon:
- Distal 1/3rd of transverse colon
- Splenic flexure
- Descending colon
- Sigmoid colon
Carcinoma of the Splenic Flexure:
- Distal 2/3rds of transverse colon
- Splenic flexure and descending colon
Vessels Ligated:
- Left branch of middle colic vessels
- Left colic vessels
- Inferior mesenteric and sigmoidal vessels in case of carcinoma of descending colon.
Surgical Techniques:
- Laparotomy through midline/left paramedian incision.
- Exploration of the abdomen for liver deposits, peritoneal deposits, ascites and other synchronous lesions.
- Assessment of the tumour for site, extent, mobility, serosal involvement and local extension.
- Mobilisation of the left colon done by incising along the avascular lateral peritoneal fold or white line of Toldt and rotating the descending colon and the sigmoid colon anteriorly and medially. Splenic flexure is mobilised by dividing the gastrocolic ligaments and phrenicocolic ligaments.
- Retroperitoneum is entered through the incision and dissection carried medially towards the ligament of Treitz.
- Retroperitoneal structures encountered during dissection are the left kidney with ureter and left gonadal vessels. Care must be taken to avoid injury to these structures.
- Turnbull’s technique or no touch isolation technique—early ligation of the vessels before manipulation of the tumour should be followed to prevent dissemination of the tumour cells during handling.
- Left colic and left branch of middle colic vessels are isolated, ligated and divided in case of carcinoma of splenic flexurInferior mesenteric and sigmoidal vessels are also ligated in case of carcinoma of descending colon.
- Level of colonic transection and anastomosis:
- Carcinoma of the splenic flexure: Proximally at the junction of right 1/3rd and left 2/3rds of transverse colon and distally at the junction descending and sigmoid colon. Colocolic anastomosis is done.
- Carcinoma of the descending colon: Proximally at the junction of right 2/3rds and left 1/3rd of transverse colon and distally at the rectosigmoid junction.
- Colorectal anastomosis is done
- Abdominal wall is closed in layers
Transverse Colectomy
Transverse Colectomy Indication:
Carcinoma of transverse colon
Structures Removed:
Whole of the transverse colon including the hepatic and splenic flexures.
Vessels Ligated:
- Middle colic vessels
- Left branch of right colic vessels
- Right branch of left colic vessels
Surgical Techniques:
- Laparotomy through midline incision
- Exploration of the abdomen for liver deposits, peritoneal deposits, ascites and other synchronous lesions.
- Assessment of the tumour for site, extent, mobility, serosal involvement and local extension.
- Mobilisation of the hepatic flexure is done by incising along the right avascular lateral peritoneal fold or white line of Toldt and rotating the hepatic flexure anteriorly and downwards. Splenic flexure is mobilised by dividing the gastrocolic ligaments and phrenicocolic ligaments.
- Turnbull’s technique or no touch isolation technique—early ligation of the vessels before manipulation of the tumour should be followed to prevent dissemination of the tumour cells during handling.
- Isolation of middle colic, left branch of right colic and right branch of left colic vessels done and ligated.
- Proximal transection is done just proximal to the hepatic flexure and the distal transection is done just distal to the splenic flexure. Colocolic anastomosis is done
- Abdominal wall is closed in layers
Sigmoid Colectomy
Sigmoid Colectomy Indications:
- Carcinoma sigmoid colon
- Diverticular disease
- Sigmoid volvulus
Structures Removed:
- Sigmoid colon
- Associated mesosigmoid
- Lymph nodes in malignancy
Vessels Ligated:
- Inferior mesenteric vessels distal to the origin of left colic vessels.
- Sigmoidal vessels
- Left branch of left colic vessels
Surgical Techniques:
- Laparotomy through midline/left paramedian incision.
- Exploration of the abdomen for liver deposits, peritoneal deposits, ascites and other synchronous lesions.
- Assessment of the tumour for site, extent, mobility, serosal involvement and local extension.
- Mobilisation of the left colon is done by incising along the avascular lateral peritoneal fold or white line of Toldt and rotating the descending colon and the sigmoid colon anteriorly and medially.
- Retroperitoneum is entered through the incision and dissection carried medially towards the origin of inferior mesenteric artery.
- Retroperitoneal structures encountered during dissection are the left ureter and left gonadal vessels. Care must be taken to avoid injury to these structures.
- Turnbull’s technique or no touch isolation technique—early ligation of the vessels before manipulation of the tumour should be followed to prevent dissemination of the tumour cells during handling.
- Inferior mesenteric vessels distal to the origin of left colic vessels, sigmoidal vessels and left branch of left colic vessels done are isolated, ligated and divided.
- Colonic transection done proximally at the junction of descending colon and sigmoid colon and distally at the rectosigmoid junction. Colorectal anastomosis is done.
- Abdominal wall is closed in layers.
Staplers In Surgery
Staplers In Surgery Principle:
They are used for apposition of tissues:
Staplers In Surgery Types:
1. Cutaneous staplers:
- Used after thyroidectomy. It is quick and gives clean apposition.
- Needs a special instrument for removal.
2. Linear staplers:
- Used to close the bowel partially or completely.
3. Circular staplers:
- Are also called EEA stapler: End-to-end anastomosis.
- Uses in surgery:
- After low or high anterior resection done for carcinoma rectum
- After oesophagogastrectomy
- Any other intestinal resection
4. GIA stapler:
- Gastrointestinal anastomosis stapler: Used for sideto-side anastomosis.
5. Endostapler:
- With the increasing use of laparoscopy surgeries for facilitating a quick and safe anastomosis, endostaplers are used for intestinal anastomos is.
- Endovascular staplers are used to ligate vascular pedicles.
- Examples: Renal pedicles during laparoscopic nephrectomy, adrenal veins during laparoscopic adrenalectomy.
Advantages of Staplers:
- Saves operating time
- The low rectal and oesophageal anastomosis have higher incidence of leakage rates. However, it can be decreased by using staplers.
Disadvantages of Staplers:
- Expensive
- Improper apposition results in leakage
Parts of the Stapler:
- Handle
- Shaft
- Head, detachable anvil + a staple cartridge.
The staples (approximately 15 in number) are present in the cartridgThe cartridge also has a circular knife.
Staplers In Surgery Contraindications:
- If the tissues which have to be approximated are under tension, they should not be stapled.
- Different lumen diameters should not be stapled end-to-end.
- If the circular head is of greater diameter than the lumen, it should not be used.
Laparoscopic Surgery
Laparoscopic Surgery Introduction and History:
- Laparoscopy made marked advances in the 1990s.
- Although the term minimally invasive surgery (MIS) is relatively recent, the history of its component parts is nearly 100 years olWhat is considered the newest and most popular variety of MIS, laparoscopy, is in fact the oldest.
- Primitive laparoscopy, placing a cystoscope within an inflated abdomen, was first performed by Kelling in 1901.
- In the late 1950s, Hopkins described the rod lens, a method of transmitting light through a solid quartz rod with no heat and a little light loss.
- Muhe in Germany began performing laparoscopicassisted cholecystectomies in 1985.
- In 1987, Mouret and Dubious performed the first video-laparoscopy in France.
- The explosion of video-assisted surgery in the past 20 years was a result of the development of compact, high-resolution, charge-coupled devices (CCDs) that could be mounted on the internal end of flexible endoscopes or on the external end of a Hopkins telescope.
- Coupled with bright light sources, fibreoptic cables, and high-resolution video monitors, the video endoscope has changed our understanding of surgical anatomy and reshaped surgical practice.
Laparoscopic Surgery Basic Instrumentation:
- 0° or 30° angled laparoscope either 5 or 10 mm in diameter attached to camera connected to video source and monitor, ports for gas connection.
- 5 mm laparoscopic instruments including Maryland dissector, blunt-tip dissecting forceps, cup-biopsy forceps, atraumatic grasping forceps, liver retractor,
- Babcocks forceps and scissors.
- 5 or 10 mm suction/irrigation device
- Laparoscopic ultrasound probe (optional)
Laparoscopic Surgery Equipment:
1. Telescope: 30°, 0° or 45°
2. Video camera: A high-resolution video camera attached to the eyepiece of the telescope acquires the image for projection on the monitor. The video image is transmitted via a cable to a video unit, where it is processed into either an analog or a digital form.
- Analog is an electrical signal with a continuously varying wave or shift of intensity or frequency of voltagDigital is a data signal with information represented by ones and zeros and is interpreted by a computer. These are the methods by which the picture is transmitted to the video monitor.
- The camera and cable are designed so that they can be sterilised in glutaraldehyde.
3. Light sources: High-intensity light is created with bulbs of mercury, halogen vapour or xenon. Since light is absorbed by blood, any procedure in which bleeding is encountered may require more light. The light is carried to the fibreoptic bundles of the laparoscope via a fibreoptic cablThe current systems create even brightness across the field.
4. Insufflators: An insufflator delivers gas from a high pressure cylinder to the patient at a high rate with low and accurately controlled pressure
5. Video monitors: High-resolution video monitors are used to display the imagThese monitors may be positioned optimally.
Anaesthesia:
- Usually done under general anaesthesia.
- Laparoscopic surgeon can influence cardiovascular performance by reducing or removing the CO2 pneumoperitoneum.
- Insensible fluid losses are negligible, and therefore, IV fluid administration should not exceed that necessary to maintain circulating volume.
- Minimally invasive surgical procedures are often outpatient procedures. So, short-acting anaesthetic agents are preferable.
- Since, the factors that require hospitalisation after laparoscopic procedures include the management of nausea, pain and urinary retention, the anaesthesiologist should minimise the use of agents that provoke these conditions and maximise the use of medications that prevent such problems.
- Critical to the anaesthesia management of these patients is the use of non-narcotic analgesics (e.g. diclofenac) when haemostasis allows it, and the liberal use of antiemetic agents, such as ondansetron and steroids.
Procedure and Principles:
The unique feature of laparoscopic surgery is the need to lift the abdominal wall from the abdominal organs by creating pneumoperitoneum.
Gases Used:
Laparoscopic Access:
- The requirements for laparoscopy are more involved because the creation of a pneumoperitoneum requires that instruments of access (trocars) contain valves to maintain abdominal inflation.
- Two methods are used for establishing abdominal access during laparoscopic procedures. The first, direct puncture laparoscopy, begins with the elevation of the relaxed abdominal wall with two towel clips or a well-placed han
- A small incision is made in the umbilicus, and a specialised springloaded (Veress) needle is placed in the abdominal cavity. With the Veress needle, two distinct pops are felt as the surgeon passes the needle through the abdominal wall fascia and the peritoneum.
- The umbilicus usually is selected as the preferred point of access because, in this location, the abdominal wall is quite thin, even in obese patients. The abdomen is inflated with a pressure-limited insufflator.
- CO2 gas is used usually with maximal pressures in the range of 14 to 15 mmHg. During the process of insufflation, it is essential that the surgeon observe the pressure and flow readings on the monitor to confirm an intraperitoneal location of the Veress needle tip.
- Occasionally, the direct peritoneal access (Hasson) technique is advisablWith this technique, the surgeon makes a small incision just below the umbilicus and under direct vision locates the abdominal fascia.
Utility and Scope:
1. Basic:
- Appendicectomy
- Cholecystectomy
- Hernia repair
2. Advanced:
- Nissen fundoplication
- Heller’s myotomy
- Gastrectomy
- Oesophagectomy
- Enteral access
- Bile duct exploration
- Colectomy
- Splenectomy
- Adrenalectomy
- Lymph node dissection
- Nephrectomy
- Robotics
- Stereo imaging
- Telemedicine
3. Laparoscopy-assisted procedures:
- Hepatectomy
- Pancreatectomy
- Prostatectomy
- Hysterectomy
The Physiologic Effects of Pneumoperitoneum:
- The pneumoperitoneum has many effects that are only partially known despite years of study in humans and in animal models. There are effects resulting from the pressure within the abdomen and effects resulting from the composition of the gas used, generally carbon dioxide.
- The pressure within the abdomen from pneumoperitoneum decreases venous return by collapsing the intra-abdominal veins, especially in volumedepleted patients.
- This decrease in venous return may lead to decreased cardiac output.
- To compensate, there is an elevation in the heart rate, which increases myocardial oxygen demand.
- High-risk cardiopulmonary patients cannot always meet the demand and may not tolerate a laparoscopic procedurIn volume-expanded healthy patients with full intra-abdominal capacitance vessels (veins), the increased intra-abdominal pressure actually may serve as a pump that increases right atrial filling pressure.
- Urine output often is diminished during laparoscopic procedures and usually is the result of diminished renal blood flow owing to the cardiovascular effects of pneumoperitoneum and direct pressure on the renal veins.
- In addition to direct effects, elevated intra-abdominal pressure results in release of antidiuretic hormone (ADH) by the pituitary, resulting in oliguria that may last up to 60 minutes after the pneumoperitoneum is released.
Laparoscopic Surgery Complications of Laparoscopy:
- Injury to bowel/bladder
- Injury to major vessels
- CO2 related complications
Hypercapnia: Hypercapnia and acidosis are seen with pneumoperitoneum and are likely due to the absorption of carbon dioxide from the peritoneal cavity. Hypercapnia and acidosis that are difficult to control may follow, especially in elderly patients, those undergoing long operations and patients with pulmonary insufficiency.
Carbon dioxide embolus: The incidence of clinically significant CO2 embolism is very low, although recent reports using more sensitive tests suggest that tiny bubbles of gas are present commonly in the right side of the heart during laparoscopic procedures. Clinically important CO2 embolism may be noted by unexplained hypotension and hypoxia during the operation.
Capnothorax/pneumothorax: Capnothorax can be caused by carbon dioxide escaping into the chest through a defect in the diaphragm or tracking through fascial planes during dissection of the oesophageal hiatus. It can also be due to opening of pleuroperitoneal ducts most commonly seen on the right side.
Hernia Repair TAPP (Transabdominal Preperitoneal Mesh Repair)
Key Points In Laparoscopic Inguinal Anatomy
Space of Bogros:
This ‘preperitoneal space’ is divided into two by the posterior lamina of the transversalis fasciThe posterior compartment of this space is called the ‘Space of Bogros (proper)’, described by French anatomist Bogros in 1923. The anterior space has been termed as the ‘Vascular Space’. Medially it is continuous with the space of Retzius.
Prevesical Space of Retzius:
The preperitoneal space that lies deep to the supravesical fossa and the medial umbilical fossa is the prevesical space of Retzius (described in 1858, by Swedish anatomist Retzius). Dissection of this space during a laparoscopic hernia repair is mandatory to enable proper mesh overlap of the hernial defect to aid in proper mesh placement/fixation.
Corona Mortis/Crown of Death/Circle of Death:
- The pubic branch of the inferior epigastric artery courses in a vertical fashion inferiorly, crossing the Cooper’s ligament and anastomosing with the obturator artery. In 25–30% of individuals (can be as high as 70–80%), the pubic branch is large and can replace the obturator artery.
- This large arterial branch is called aberrant obturator artery can partially encircle the neck of a hernia sac and be injured in a femoral hernia repair. It could also be injured while exposing the Cooper’s ligament by freeing it of areolar adipose connective tissue.
- Because of this possibility an enlarged pubic branch of the inferior epigastric artery has in the past been known as the ‘Corona Mortis’. The danger of injury in this area is more significant for obturator veins.
Triangle of Doom:
- It is a misnomer. It is not a trianglIt indicates an area where it is dangerous to place staples or sutures during laparoscopic hernia surgery.
- The “triangle of doom” is an inverted “V”-shaped area with its apex at the internal (deep) inguinal ring. The “triangle of doom” is bound laterally by the gonadal vessels, and medially by the vas deferens in the male, or the round ligament of the uterus in the female.
- Within the boundaries of this area you can find the external iliac artery and vein.
- Injury to these vessels can be catastrophic.
Triangle of Pain: Formed medially by gonadal vessels, laterally by iliopubic tract and inferiorly by peritoneal reflection. It contains lateral femoral cutaneous nerve, genital femoral nerve.
Hernia Repair TAPP Introduction: Novel method used for hernias wherein transabdominally (intraperitoneal) dissection is done through a laparoscope, and a mesh placed in the preperitoneal space.
Hernia Repair TAPP Indication: Large indirect hernias and irreducible hernias.
Hernia Repair TAPP Procedure:
- 10 mm infraumbilical port is used for the laparoscopic camera.
- 5 mm ports are placed one on each side on pararectal point at or above the level of umbilicus, so as to achieve adequate triangulation.
- Once ports are inserted, the hernial sac is recognized and the contents are reduced by pulling it transabdominally using a dissector (laparoscopic).
- Hernial sac is dissected in the preperitoneal plane after incising at the upper part of the hernial sac opening.
- Once the sac is dissected and excised, a prolene mesh is placed in the preperitoneal spacIt is fixed to the pubic bone using tacks. Peritoneum is closed with prolene sutures.
Hernia Repair TAPP Complications:
- Mesh displacement
- Intestinal obstruction, if the mesh displaces into the peritoneum.
- Expensive
- Higher recurrence rates
Hernia Repair: TEP (Totally Extraperitoneal Repair)
Hernia Repair TAPP Indications:
- Recurrent hernia
- Bilateral inguinal hernias
- Indirect/direct/femoral hernias
Hernia Repair TAPP Contraindications:
- Obstructed/strangulated hernias
- Ascites
- Bleeding disorders
This surgery has surpassed the TAPP procedure and is turning out to be a promising procedure for management of hernias.
Hernia Repair TAPP Procedure:
- Subumbilical incision (10 mm) placed
- Extraperitoneal space is created by passing the scope between the rectus muscle and the posterior rectus sheath medial to the muscle bundle edge.
- Initial dissection is carried out using laparoscope itself and inflation of CO2.
- 2 more 5 mm ports are placed in the midline 4 cm and 8 cm below the 1st port respectively.
- Dissection is carried out medially till the pubic tubercle, iliopectinate ligament and laterally till the iliac vessels and inferior epigastric vessels. Once adequate space is dissected, the sac is reduced by pulling it down from the inguinal canal (reduction of sac) and a 15 × 15 cm mesh is placed and spread.
- Mesh may be sutured, left as it is or fixed with tackers.
- Both sides can be done together through the same ports.
Hernia Repair TAPP Complications:
- Cord/vas injuries
- Inadvertent opening of the sac/peritoneum and creation of pneumoperitoneum
- Seroma formation
- Infection
Advantages of TEP:
- Approach is totally extraperitoneal
- Smaller incisions
- No need for fixing mesh
- Peritoneum is intact
Sils (LESS)
Sils (LESS) Introduction:
- Single port access (SPA) surgery, also known as laparoendoscopic single-site surgery (LESS), single incision laparoscopic surgery (SILS) or single port incision less conventional equipment-utilising surgery (SPICES) or embryonic natural orifice transluminal endoscopic surgery (E-NOTES) is an advanced minimally invasive surgical procedure in which the surgeon operates almost exclusively through a single entry point, typically the patient’s navel.
- SPA surgical procedures are like many laparoscopic surgeries in that the patient is under general anaesthesia; insufflated and laparoscopic visualisation is utilised.
- In laparoendoscopic single-site surgery (LESS), a single small incision is used at the entry point rather than four to five small incisions.
- All surgical instruments are placed through this small incision and also the incision site is located in the left abdomen or umbilicus. In general, SILS techniques take the same amount of time to do as traditional laparoscopic surgeries.
- However, SILS is recognised as to be a more complicated procedure because it involves manipulating three articulating instruments through one access port.
- Obesity, severe adhesions, or scarring from previous surgeries are a few cases, SILS may not be possibl Failure rates are high.
Question 1. How SILS Differs from Traditional Laparoscopic Surgery?
Answer:
- In single incision laparoscopic surgery, only one incision of around 1.5–2 cm is made just below the umbilicus to allow placement of three thin 5 mm port side by side parallel to each other.
- Port, a specially designed port is inserted into the abdomen; this port carries the telescope and laparoscopic instruments.
- Steps of surgical procedure are similar to the conventional laparoscopic surgery.
- As there is only one incision, pain is less as compared to traditional laparoscopic surgery and recovery is faster. The healed incision leaves practically no scar, thus making SILS cosmetically a superior option.
- In 5 to 10% patients, it may not be possible to complete the operation by SILS due to technical difficulties. One has to place one or two additional ports and completes the procedure in the traditional laparoscopic manner.
Natural Orifice Transluminal Endoscopic Surgery (Notes)
Natural Orifice Transluminal Endoscopic Surgery Introduction:
- It means surgery performed endoscopically by initially passing the flexible endoscope through the body’s natural orifices, like the mouth, anus, vagina, or urethra, to achieve access into areas that would not otherwise be accessible endoscopically, such as the abdomen and pelvis.
- Kalloo’s did the first transgastric peritoneoscopy in 2004. In India, Dr GV Rao and Dr Nageshwar Reddy from Hyderabad, performed the first—NOTES in a patient who had appendicitis with extensive scars over the abdominal wall. The entry from abdomen was not possiblThey performed transoral, transgastric appendicectomy.
Natural Orifice Transluminal Endoscopic Surgery Advantages:
- Less invasive
- No abdominal incision
- Reduction in postoperative pain
- Wound infection, hernia formation and adhesions are very less.
Commonly Performed NOTES:
- Transgastric appendectomy
- Transvaginal cholecystectomy
Future Upcoming Technologies:
- Magnetically anchored and guidance systems (MAGS) are designed to manoeuvre intra-abdominal instruments. They use the external handheld magnet.
- The fundus of the gall bladder can be retracted above the costal margin by coupling the interior aspect of an external magnet. The graspers are situated on the gall bladder with the help of endoscopic biopsy forceps.
- Magnets may become valuable, within the operating room.
Vaaft Technique
Vaaft Technique Introduction:
It is performed for the surgical treatment of complex anal fistulas and their recurrences. Key points are the exact localisation of the internal fistula opening under vision, the fistula treatment from inside, and the hermetic closure of the internal opening. No risk of faecal incontinence as no sphincter damage—one of the great advantages over the conventional treatment.
Vaaft Technique Materials:
- Fistuloscope, a unipolar electrode connected to a high frequency unit, a fistula brush and a forceps.
- A semicircular or linear stapler and 0.5 ml of synthetic cyanoacrylate with a tiny catheter are used as well.
- The fistuloscope is equipped with an optical channel, a working channel and an irrigation channel. The working length adds up to 18 cm; the use of a handle reduces it to an effective length of 14 cm.
- The optimal patient positioning is the lithotomy position. Spinal anaesthesia is required.
- The fistuloscope is connected to the Karl Storz equipment and to the washing solution bag (5000 cc glycine and mannitol 1% solution).
The Technique:
It comprises a diagnostic phase and an operative phase.
The Diagnostic Phase:
- The fistuloscope is inserted through the external fistula opening with the washing solution (glycine 1% and mannitol 1%) already running. Thus, it provides clear view of the fistula pathway which is seen on the screen.
- With right index finger in the rectum, fistuloscope is guided slowly into the fistula.
- Complete relaxation of the surrounding tissue induced by the spinal anaesthesia helps in gentle up and down movements to advance the fistuloscope.
- The continuous flow of the glycine-mannitol solution allows for an optimal view of the fistula’s inside up to the internal opening.
- At this stage, insert an anal retractor in order to localise the internal fistula opening by looking for the light of the telescope in the rectum or anal canal.
- When the fistuloscope exits through the internal opening the rectal mucosa clearly appears on the screen. At this point, two or three stitches are put, in two opposite points of the internal opening margin in order to isolate those points and not to lose them.
The Operative Phase:
- First locate the internal opening. From the internal opening to external opening, the fistula wall and all granulation tissues are coagulateProcedure is done slowly so that fistula is destroyed under vision using a unipolar electrodAll the necrotic material is removeAbscess cavity is irrigated.
- Fistuloscope is removed at this stagThe assistant stretches the threads towards the internal rectal space or rather the anal canal using a straight forceps in order to lift the internal fistula opening at least 2 cm into the shape of a volcano.
- Subsequently, stitch is inserted at the volcano’s base and complete the mechanical cutting and suturing by using a linear stapler. The hermetic closure of the internal fistula opening can also be accomplisheThis also depends on the internal opening position. Using a semicircular stapler, the suture will be horizontal. Using a linear stapler, the suture will be vertical.
- Last step is insertion of 0.5 ml of synthetic cyanoacrylate after the suture/staple line via the fistula pathway to further reinforce the suturIt helps in perfect closure of the fistula opening.
- This procedure assures a perfect excision and a hermetic closure of the internal fistula opening, excluding the risk of stool passagSince the suture is situated tangential to the sphincter, the postoperative pain is low even if the suture falls both in the anal canal and the rectum.
Vaaft Technique Conclusion:
- The advantages of the VAAFT technique are: No surgical wounds on the buttocks or in the perianal region, there is complete certainty in the localization of the internal fistula opening, and the fistula can be completely destroyed from the inside.
- Since operations are done from inside, no damage is caused to the anal sphincters. The risk of postoperative faecal incontinence is excluded.
Robotic Surgery:
- The term robots was introduced and coined in 1921, “robota” meaning forced labour. The first documented use of robotic-assisted surgery was in 1985. PUMA 560 robotic surgical arm was used successfully in a delicate neurosurgical biopsy, a non-laparoscopic surgery.
- The first laparoscopic procedure involving a robotic system was a cholecystectomy done in 1987. The following year the same PUMA system was used to perform a transurethral resection. da Vinci Surgical System is the first robotic system approved by the FDA for general laparoscopic surgery.
- The da Vinci system’s 3D magnification screen allows the surgeon to view the operative area with the clarity of high resolution. The “Endo-wrist” features of the operating arms precisely replicate the skilled movements of the surgeon at the controls and filter out any shaking, greatly improving accuracy in small operating spaces.
- da Vinci system has been approved by the FDA for use in:
- Urological surgeries, general laparoscopic surgeries, general noncardiovascular thoracoscopic surgeries and thoracoscopically-assisted cardiotomy procedures. There are three different types of robotic surgery systems currently in usThe main difference between each system is how involved a human is in the process.
1. Supervisory controlled systems: The surgeon inputs data into the robot and the robot does all of the following surgery.
2. Tele-surgical systems: Cutting and sewing is performed by a surgeon at a console remote from the patient. The surgeon can be miles away at another site while performing this type of surgery.
3. Shared control systems: Doctors perform the work with the assistance of the robot technology, simultaneously.
Vaaft Technique Advantages:
- Surgeons are able to perform more complex tasks (increases precision), physically easier, less awkward positioning for the surgeon. Procedures reduce the risk of death, complications, and hospital stay. It provides enhanced 3-D high-definition visualisation.
- For the patients: Reduced trauma to the body, less risk of infection along with faster recovery.
Vaaft Technique Disadvantages:
- More expensive than traditional surgery.
- Removal of physical contact with surgery surface.
- The procedure can take nearly twice as long, depending on how well the surgeon knows the equipment.
- The size of the actual equipment can take up a lot of space inside the operating room.
- All operating instruments are NOT compatible with the technology required for robotic surgery.
Common procedures which can be done by da Vinci surgical system:
- Bladder cancer – Obesity
- Colorectal cancer – Prostate cancer
- Coronary artery disease – Throat cancer
- Endometriosis – Uterine fibroids
- Gynaecologic cancer – Uterine prolapse
- Kidney cancer – Mitral valve prolapse
Energy Sources In Surgery
High Frequency (Hf) Electrosurgery
Principle involves passage of electric current through tissue by means of potential difference (voltage). The resultant flow of electrons excites the tissue molecules, notably water, creating heat energy which causes water evaporation and tissue coagulation.
HF electrosurgery can be monopolar or bipolar. Here, the current escapes from electrode tip into the receptive tissue and exits through the grounding paUnmodulated continuous sine wave in voltage range 200–500 mV is used for electrocutting.
Uses of Electrocautery:
- To achieve haemostasis
- Removal of skin tags
- Treating very small, early basal cell carcinoma
- Removal of erosions of cervix
- Removal of condylomata, cutaneous acanthoma, warts, etc.
Bipolar Electrocautery:
Heat energy is concentrated between two electrodes and does not dissipate throughout the tissuHence,
- Small volume of tissue is injured
- Less risk of burning injury
- Safe with pacemakers
- Excellent for obtaining haemostasis in areas that may be in close proximity to delicate structures, e.g. head and neck surgery.
Monopolar Electrocautery:
Heat energy and thus tissue injury can extend for some distance away from the point of contact. Hence, great care should be taken to avoid;
- Direct contact with a hollow viscus as this may lead to perforation.
- Close proximity to a major blood vessel as it may cause vessel wall injury
Harmonic Scalpel
- It is a high frequency mechanical energy device which uses ultrasound technology. This instrument has a hand held ultrasound transducer and scalpel. While using by hand or foot pedal, scalpel vibrates in the range of 20,000–55,500 Hz.
- During this process it cuts the tissues and seals the tissues. Process of sealing is by protein denaturation. No ligatures are required and perfect haemostasis is obtaineScalpels have different sizes.
- It has three compatible probes that are the shear, blade and a hook. The shear can coagulate vessels up to 5 mm, whereas the hook and blade only 2 mm in diameter.
- Types of vessels which can be coagulated and sealed are up to 5 mm diameter. Newer instruments can coagulate vessel up to 7 mm diameter. However, to be on the safer side, 4–5 mm diameter arteries such as right colic artery and veins, superior thyroid arteries and veins and such many vessels can be sealed and cut.
- Advantages of harmonic scalpel: No smoke, no lateral thermal tissue injury, no ligatures and less operative timThus it is the popular choice of energy sources in laparoscopic surgeries. It can also be used for open surgeries—a few examples are excision of pile masses (haemorrhoidectomy) and raising flaps for mastectomies.
- Disadvantages: More time for coagulation. A spurting artery can be ligated by a haemostat or coagulated by cautery than harmonic scalpel. It is costly.
Lasers In Surgery
- Light Amplification by Simulated Emission of Radiation
- Molecules which are placed in a compact area are activated when power is passed through. As a result of this, they move in different directions, they hit each other, releasing energy. This energy is used as laser to the area whenever required.
Lasers In Surgery Types:
- Argon laser
- Neodymium: Yttrium-aluminium-garnet laser (Nd:YAG laser)
- CO2 laser
- Neon laser
Lasers In Surgery Advantages and Disadvantages:
- Most important advantage is a bloodless field— specially useful in head and neck surgeries and ENT surgeries.
- It is quick and there is less tissue trauma
- Expensive
Lasers In Surgery Precaution:
To avoid injuries to normal tissues, all reflecting instruments should be avoided so that the laser does not get reflected.
Lasers In Surgery Clinical Applications:
- Vascular malformation of the GIT
- Endoscopic laser for advanced carcinoma oesophagus to relieve obstruction and dysphagia.
- Obstructed colorectal cancer
- Liver resections: Nd:YAG laser combined with CUSA can be used for liver resections.
- CO2 laser and Nd:YAG laser can be used for haemorrhoidectomy.
Miscellaneous
When To Do Prophylactic Surgery?
- Prophylactic bilateral mastectomy in BRCA1 and BRCA2 patients.
- Prophylactic total colectomy and ileoanal pouch in familial polyposis coli patients.
- Prophylactic total thyroidectomy in familial medullary carcinoma thyroid patients.
- Prophylactic cholecystectomy in Pima Indians.
- Prophylactic vagal sparing transhiatal oesophagectomy (THE) for severe dysplasia.
- Prophylactic gastrectomy-E-cadherin mutation.
Please Read These Instructions
- Students are requested to confirm the list of operations which will be asked in the examination with their teachers in their respective medical colleges and be prepared for exams. You should realise that what operation an undergraduate student is expected to know in more detail is not stated clearly in the syllabus.
- Nevertheless, you do not lose anything trying to understand more operations. Rather, it may help you in your postgraduate entrance examinations.
- The last four chapters are important for viva voce examination in general surgery. The questions given in these chapters are most commonly askeThis does not mean, however, that they are the only questions askeAs the subject is vast, the number of questions that can be asked can be unlimiteThe purpose of viva voce section is to see how much the student knows as well as the depth and understanding of the subject.
- Our best wishes to you once again. Enjoy reading Manipal Manual of Surgery, 6th edition—Authors.
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