General Procedures

General Procedures

• In this PowerPoint, you will find information on different types of “oscopies”, as well as Open procedures and their corresponding Laparoscopic procedures.

GI Endoscopic and Laparoscopic Procedures

Oscopies!SigmoidoscopyColonoscopyERCPCholedochoscopyEsophagoscopyEGD

Oscopies!Sigmoidoscopy

Flexible or rigid scopes are used.

Used to evaluate conditions of the rectum.

IV sedation is recommended.

Oscopies!

Colonoscopy A procedure done to

check for abnormalities in the colon.

Done under IV sedation

Biopsies, pictures, and brushings can be taken through endoscope.

Oscopies!ERCP

(Endoscopic Retrograde Cholangiopancreatography) Used in visualization of the soft tissues and sphincter fibers of

the papilla and intraduodenal duct. Can lead to ERS, Endoscopic Retrograde Sphincterotomy,

which permit stones to move into the duodenum.

Oscopies!Choledochoscopy

Visualization of the gallbladder, cystic duct and common bile duct using a scope.

Oscopies!Esophagoscopy

Performed on the esophagus.

Used to evaluate pain or dysphagia (painful swallowing).

Can be used for foreign body removal, hemostasis, dilation, and biopsies.

Not to be confused with an EGD (Esophagogastroduoden-oscopy)

EGDEsophagogastroduodenoscopy.A diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum.

EGD VideoOld EGD Fast

http://www.youtube.com/watch?v=T4h1PurNOPw

Laparotomy

GI Open ProceduresOperative Sequence

Laparotomy• Overall Purpose of Procedure:

• An Exploratory Laparotomy is performed to examine he abdominal cavity when less invasive measures, such as x-rays and CT scans, fail to confirm a diagnosis.

• Case length – 30 mins to many hours.

Laparotomy

• Define the procedure: • Abdominal exploration may be used to help diagnose

many diseases and health problems, including:• Inflammation of the appendix (acute appendicitis) • Inflammation of the pancreas (acute or chronic

pancreatitis) • Pockets of infection (retroperitoneal abscess, abdominal

abscess, pelvic abscess) • Endometriosis • Inflammation of the fallopian tubes (salpingitis) • Scar tissue in the abdomen (adhesions) • Cancer of the ovary, colon, pancreas, liver

Laparotomy• Inflammation of an intestinal pocket (diverticulitis) • Hole in the intestine (intestinal perforation) • Pregnancy outside of the uterus (ectopic pregnancy) • This surgery may also be used to determine the extent of

certain cancers, such as Hodgkin's lymphoma (also known as Hodgkin's disease, a type of lymphoma characterized clinically by the orderly spread of disease from one lymph node group to another and by the development of systemic symptoms with advanced disease.)

• Wound Classification: 1 (yet depends on what you do during the case)

Operative Sequence• 1- Incision• 2- Hemostasis• 3- Dissection • 4- Exposure• 5- Procedure (Specimen Collection possible)• 6- Hemostasis • 7- Irrigation• 8- Closure• 9- Dressing Application

Laparotomy• Instrumentation: Major/Minor Instrument Tray. • What basic instruments will you expect to see in this

tray? • Positioning: The patient is in supine position, arms

tucked at the side or on arm boards. Surgeon stands on the left side of the patient.

• Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from midchest to groin area and far lateral on both sides.

• Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.

Laparotomy Begin your Operative Sequence

• Incision: 10 kb on #3 handle for incision.

• A midline abdominal incision is made.

Laparotomy cont. Operative Sequence

• Hemostasis: Handheld Bovie, hemostats, free ties or clips are utilized.


• Dissection and Exposure:• Army-Navys• Richardsons• Balfour• Bookwalter


• Exploration and Isolation:• This entire step will depend on what

procedure is needed!• Surgical

Repair/Removal/Specimen Collection:• This entire step will depend on what

procedure is needed!


• Hemostasis and Irrigation:• All bleeding is controlled with cautery. • Use of warm Saline to irrigate.


• Closure:• Will use strong suture for peritoneal

layer such as 0 looped PDS.• Will use a 0-Vicryl to close the

fascial/muscle layer and a 4-0 Monocryl for skin.

• Skin staples are always an option.

Laparotomy

• Major Arteries:• Internal thoracic artery• The superior epigastric artery• Aorta• External iliac artery: the inferior

epigastric and deep circumflex arteries

• Inferior phrenic artery, branch of the abdominal aorta.

• Lower posterior intercostal and subcostal arteries, branches of thoracic aorta.

• Lumbar arteries, from abdominal aorta.

GI Laparoscopic ProceduresOperative Sequence

Laparoscopic Appendectomy

Laparoscopic Appendectomy• Overall Purpose of Procedure:

• Appendectomies are performed to treat appendicitis, an inflamed and/or infected appendix. An infected appendix can leak and infect the entire abdominal area, which can be deadly.

• An irritated appendix can rapidly turn into an infected and ruptured appendix, sometimes within hours. A ruptured appendix can be life threatening. When the appendix ruptures, bacteria infect the organs inside the abdominal cavity, causing peritonitis. The bacterial infection can spread very quickly and be difficult to treat if diagnosis is delayed.

Laparoscopic Appendectomy• Define the procedure: Removal of the

appendix with the aid of a laparoscope.• Wound Classification: 2 if not ruptured

and no spillage of bowel contents during procedure.

• Case length – 30 mins to 1hour.

Laparoscopic Appendectomy• Instrumentation: Laparoscopic Instrument Tray. • What other basic instruments will you expect to see in this tray?

• Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient with the camera holder/assistant. Monitor should be placed near right hip facing towards surgeon. Trendelenburg? WHY?

• Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from Chest to just above pubic hair and far lateral on both sides. Pre-prep hair trimming might be necessary.


Laparoscopic AppendectomyBegin your Operative Sequence

• Incision: Two towel clips around umbilicus.• 15 kb on #3 handle

for incision.• Veres Needle and

CO-2 on high flow.

Laparoscopic Appendectomycont. Operative Sequence

• Hemostasis: Can be from multiple means. The pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.


• Dissection and Exposure:• Total of 3 trocars should be used • Two 10mm (umbilical and left

lower quadrant) and one 5 mm right upper quadrant trocar

• The right upper quadrant trocar can be moved below the bikini line in females.

• Camera/scope placed into pneumoperitineum.

• In most cases, no other dissection or exposure is needed.


• Exploration and Isolation:• An atraumatic grasper [Endo Babcock, Maryland,

Bowel Grasper, Dolphin Nose Grasper etc] is inserted via the right upper quadrant trocar. The cecum (from the Latin caecus meaning blind) is retracted upward toward the liver. In most cases, this will elevate the appendix in the optical field of the telescope.

• The appendix is grasped at its tip with a 5 mm bowel grasper via the RUQ trocar. It is held in upward position


• Surgical Repair/Removal/Specimen Collection:• Left lower quadrant (LLQ) grasper is used to create a mesenteric

window behind the base of the appendix. A grasper is used to create a mesenteric window under the base of the appendix. The window should be made as close as possible to the base of the appendix.

• The base of the appendix is then separated from it’s cecal base with either an endo-loop suture and scissors or a stapling device. Visualization of the staple line is a must to insure no leakage of bowel content and no bleeding is present.

• The mesoappendix (the portion of the mesentery connecting the ileum to the appendix) is divided and ligated, either with cautery or a stapling device.

• Removal of the appendix with Endo-pouch• or Kellys/Peons

Laparoscopic Appendectomy


• Hemostasis and Irrigation:• The intra-abdominal cavity is irrigated thoroughly with

normal saline.• All bleeding is controlled with a cautery-capable endo-

instrument.• The abdomen should be examined for any possible

bowel injury or hemorrhage. All the instruments and ports should be carefully and slowly removed while the CO-2 in the pneumoperitineum is released.


• Closure:• Closure will be surgeon specific. Some

Surgeons today will not close any layer other than skin.

• Other surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin.


Laparoscopic Appendectomy• Major Arteries: The appendix is supplied by the

appendicular artery , branch of the ileocolic artery.

http://www.bartleby.com/107/249.html#i1073

Laparoscopic Appendectomy• Major Veins: The ileocolic vein, a tributary of the

superior mesenteric vein, drains the blood of the appendix.

• Major Nerves: The nerves of the appendix are derived from

the coeliac and superior mesenteric ganglia.

ReferencesSites of Interest

• http://www.madsci.org/posts/archives/1998-02/887299251.An.r.html• http://www.laparoscopyhospital.com/Laparoscopic_Appendicectomy.doc• http://www.surgeryencyclopedia.com/A-Ce/Appendectomy.html• http://www.healthsystem.virginia.edu/UVAHealth/peds_digest/appendic.cfm• http://www.drugs.com/enc/appendectomy.html

http://www.madsci.org/posts/archives/1998-02/887299251.An.r.html

http://www.laparoscopyhospital.com/Laparoscopic_Appendicectomy.doc

http://www.surgeryencyclopedia.com/A-Ce/Appendectomy.html

http://www.healthsystem.virginia.edu/UVAHealth/peds_digest/appendic.cfm

http://www.drugs.com/enc/appendectomy.html

Appy Video• Lap Appy per EES-Edu

http://www.eesedu.com/dtcf/pages/GS_Procedure.htm?pgn=4


Open Appendectomy

• Overall Purpose of Procedure:• Appendectomies are performed to treat appendicitis, an inflamed

and/or infected appendix. An infected appendix can leak and infect the entire abdominal area, which can be deadly.

• An irritated appendix can rapidly turn into an infected and ruptured appendix, sometimes within hours. A ruptured appendix can be life threatening. When the appendix ruptures, bacteria infect the organs inside the abdominal cavity, causing peritonitis. The bacterial infection can spread very quickly and be difficult to treat if diagnosis is delayed.

Open Appendectomy• Define the procedure: Removal of the

appendix via open approach.• Wound Classification: 2 if not ruptured

and no spillage of bowel contents during procedure.

• Case length – 30 mins to 1.5 hours.

Open Appendectomy• Instrumentation: Minor/Major Instrument Tray. • What basic instruments will you expect to see in this tray?

• Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient. Trendelenburg? WHY?



Open Appendectomy

• Incision: McBurneys incision

Which one isthe McBurney?

Open Appendectomy


Open Appendectomy• Dissection and Exposure:

• Metz scissors and Debakey forceps.• Bovie for dissection and hemostasis• Army-Navy Ret, Small Rich or even Goulet for retraction and exposure of

surgical site.• Possible need of Balfour Retractor in obese patients ONLY.

Open Appendectomy

• Exploration and Isolation:• Bowel is mobilized with Babcock clamp.• Appendix is located and brought up through the incision site.

Open Appendectomy• Surgical Repair/Removal/Specimen Collection:

• Moist towel is placed around the base of the appendix to keep incision site clean when “ectomy” is performed.

• Using Metz scissors, the meso-appendix is isolated.• It is double clamped, cut and vasularity ligated with

silk ties.• Why silk?• Uses 2-0 or 3-0 to tie. Have suture scissors ready.

Open Appendectomy• Surgical Repair/Removal/Specimen Collection:

• Surgeon will clamp base of the appendix with a Kelly clamp.

• Have a heavy silk tie ready to pass around the Kelly, possibly 2 ties.

• Surgeon will run a purse string suture around the base of the appendix (called the “stump”).

• Why do they do this?• Appendix is ready to be excised.

Open Appendectomy• Surgical Repair/Removal/Specimen

Collection:• Bring up pan (emesis basin?) to place dirty

instruments into.• Surgeon can use Metz or 10 kb to excise

Appendix, making incision ABOVE the silk tie.• Surgeon will pass off specimen to you.• Surgeon will ask for Kelly clamp.


Collection:• Surgeon will grasp the remainder of the stump

with the Kelly clamp and invert the stump INTO the Cecum.

• The purse-string suture is then• tightened, thus burying• the appendicle stump.


Collection:• Remember that instruments that come into

contact with the INTERIOR of bowel are considered contaminated and need to be kept separate form other clean/sterile instruments.

• Remove them from your immediate field and make sure you don’t go back to them (even when you count!).

Open Appendectomy• Hemostasis and Irrigation:

• The intra-abdominal cavity is irrigated thoroughly with normal saline.

• All bleeding is controlled with a cautery.• The abdomen should be examined for any possible bowel

injury or hemorrhage.

Open Appendectomy• Closure:

• Surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin.

• Skin staples are always an option.• Penrose drain might be required.


Laparoscopic Cholecystectomy

Laparoscopic Cholecystectomy

• Overall Purpose of Procedure:• The surgery is usually done if the organ is inflamed or

obstructed, if gallstones are causing pancreatitis, or if cancer is suspected.

Laparoscopic Cholecystectomy• Define the procedure: Removal of the

gallbladder with the aid of a laparoscope.• Wound Classification: 2• Case length – 30 mins to 1 hour.

Laparoscopic Cholecystectomy• Instrumentation: Laparoscopic Instrument Tray. • What other basic instruments will you expect to see in this tray?

• Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient with the camera holder/assistant on opposite side of bed. Monitor should be placed near right hip facing towards surgeon. Reverse Trendelenburg? WHY?



Laparoscopic Cholecystectomy Begin your Operative Sequence

• Incision: Two towel clips around umbilicus.• 15 kb on #3 handle

for incision.• Veres Needle and

CO-2 on high flow.

Laparoscopic Cholecystectomy cont. Operative Sequence

• Hemostasis: Can be from multiple means. The pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.


• Dissection and Exposure:• 4 ports inserted• Once all the four ports are

in position the fundus of the gallbladder is grasped by the assistant and flipped upwards and over the superior edge of the right lobe of liver.


• Exploration and Isolation:• The cystic pedicle, a triangular fold of peritoneum, contains the

cystic duct and artery, the cystic node and a variable amount of fat.• The pedicle will need to be cleared of adhesions.


• Surgical Repair/Removal/Specimen Collection:• Dissection of the cystic pedicle

will be carried out.• Isolation of the Cystic Artery

and Cystic Duct from surrounding tissue will begin. (Operative Cholangiogram is always a possibility)


• Cystic Artery and Cystic Duct will be ligated with 5mm or 10mm endo-staples, usually 2 distal, one proximal to gallbladder.

• After ligation of both vessels are complete, MD will switch from cautery-capable dissectors to L or J hook to remove the gallbladder from the liver bed.

• Once the gallbladder has been freed from the liver bed, it will be removed with an Endo-pouch or Kellys/Peons.


• Hemostasis and Irrigation:• The intra-abdominal cavity is irrigated thoroughly with

normal saline.• All bleeding is controlled with a cautery-capable endo-

instrument of Surgeons choice.• Special attention is focused on the liver bed. Highly

vascularized area.• The abdomen should be examined for any possible

bowel injury or hemorrhage. All instruments and ports should be carefully and slowly removed while the CO-2 in the pneumoperitineum is released.


• Closure:• Closure will be surgeon specific. Some


• Other surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin.


Laparoscopic Cholecystectomy• Major Arteries: The gallbladder is supplied by the cystic

artery, which commonly arises from the right hepatic artery, in the angle between the common hepatic artery and the cystic duct.

• Major Veins: Cystic veins join the right branch of the hepatic portal vein. The portal vein drains blood from all of the intra-abdominal gut.

• Major Nerves: The Vagus nerve, which controls the movement

of food from the stomach through the digestive tract.

Right Hepatic Artery, Portal Vein and IVC


http://www.laparoscopyhospital.com/lap_chole.htm

Lap Chole per EES EDU

Single Site Laparoscopic Cholecystectomy EES-EDU

http://www.laparoscopyhospital.com/lap_chole.htm




Open Cholecystectomy

• Overall Purpose of Procedure:• The surgery is usually done if the organ is

inflamed or obstructed, if gallstones are causing pancreatitis, or if cancer is suspected.

Open Cholecystectomy• Define the procedure: Removal of the

gallbladder via open approach. Rarley done unless patient is severely obese or per surgeon request.

• Wound Classification: 2• Case length – 1 hour to 3 hours.

Open Cholecystectomy• Instrumentation: Minor/Major Instrument Tray. • What basic instruments will you expect to see in this tray?

• Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient. Reverse Trendelenburg? WHY?




• Incision: R sub-costal or R paramedian incision

Open Cholecystectomy• Dissection and Exposure:

• Metz scissors and Debakey forceps.• Bovie• Army-Navy Ret, Small Rich or even Goulet for retraction and exposure of

superficial site.• Deaver or Harrington retractor for deeper retraction.• Possible need of Balfour Ret.


• Exploration and Isolation:• The Liver is covered with moist laps for moisture retention

and protection while it is retracted towards the patients head.• This peritoneal is removed from base of gallbladder ( cystic

pedicle as mentioned before) for exploration of the cystic artery and duct.

• May need long instruments: Provide Examples!

Open Cholecystectomy• Surgical Repair/Removal/Specimen

Collection:• Using right angles or tonsils, the surgeon will

ligate both ducts.• Remember the steps?• Clamp, Clamp, Cut, Tie, Tie?• Uses silk suture, why?• Will use 0 or 2-0 silk free ties.


Collection:• Once both ducts are clamped, doc will use metz

(possible long version) to ligate vessels.• Pass up silk ties on passer (either Tonsil or

Right Angle clamp).• Be ready with your suture scissors.


Collection:• Once all ducts have been cut free and bleeding is controlled

we will begin to remove the gallbladder from the liver bed.• Major bleeding will begin at this stage due to the liver being

highly vascularized.• Dissection with Metz, Long Debakeys and Right Angle

Clamps.• Once gallbladder is removed, may used small Chromic

suture to tie off bleeders. What type of needle do you think they will need? Tapered or cutting? Why?

Open Cholecystectomy• Hemostasis and Irrigation:

• The intra-abdominal cavity is irrigated thoroughly with normal saline.

• All bleeding is controlled with a cautery.• Special attention is focused on the liver bed. Highly

vascularized area.• The abdomen should be examined for any possible bowel

injury or hemorrhage.

Open Cholecystectomy• Closure:

• Surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin.

• Skin staples are always an option.• Penrose drain might be required.

Open Cholecystectomy• Major Arteries: The gallbladder is supplied by the cystic

artery, which commonly arises from the right hepatic artery, in the angle between the common hepatic artery and the cystic duct.

• Major Veins: Cystic veins join the right branch of the hepatic portal vein. The portal vein drains blood from all of the intra-abdominal gut.

• Major Nerves: The Vagus nerve, which controls the movement

of food from the stomach through the digestive tract.

Right Hepatic Artery, Portal Vein and IVC


Laparoscopic Herniorrhaphy(Inguinal)

Laparoscopic Herniorrhaphy

Overall Purpose of Procedure: Hernias present as bulges in the groin area that can become more

prominent when coughing, straining, or standing up. They are often painful, and the bulge commonly disappears on lying down. The inability to "reduce", or place the bulge back into the abdomen usually means the hernia is "incarcerated," often necessitating emergency surgery.

As the hernia progresses, contents of the abdominal cavity, such as the intestines, can descend into the hernia and run the risk of being pinched within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine caught in the hernia is compromised, the hernia is deemed "strangulated," and gut ischemia and gangrene can result, with potentially fatal consequences.


Define the procedure: The surgical repair of a hernia. In a laparoscopic inguinal hernia repair the inguinal region is approached and hernia repair performed from the interior side instead of the classical open

external access.Wound Classification: 1Case length – 1 hourto 2 hours.

Operative Sequence

1- Incision2- Hemostasis3- Dissection 4- Exposure5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation8- Closure9- Dressing Application


Instrumentation: Laparoscopic Instrument Tray. What other basic instruments will you expect to see in this tray?

Always have the possibility of open procedure – might need a minor tray.

Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient with the camera holder/assistant either across the table or above the surgeon. Monitor should be placed at the F.O.B. WHY?

Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from navel to mid thigh and all of groin area and far lateral on both sides.

Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.

Laparoscopic Herniorrhaphy Begin your Operative Sequence

Incision: 15 kb on #3 handle for incision.

Laparoscopic Herniorrhaphy cont. Operative Sequence

Hemostasis: Can be from multiple means. The pressure of the trocars/balloons entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.


Dissection and Exposure: An inflatable balloon is

placed in the extraperitoneal space of the inguinal region. Inflation of the balloon creates a working space.

See diagram > >> Total of three trocars


Dissection and Exposure: Trocar placement Pump device and

second ballon used to maintain balloon created space.


Exploration and Isolation: An atraumatic grasper [Endo Babcock,

Maryland, Bowel Grasper, Dolphin Nose Grasper etc] is inserted via the trocar to assist in bowel mobilization. The hernia sac is reduced, and a large piece of mesh is placed to cover the indirect, direct and femoral areas of the inguinal region. The mesh is held in place by metal staples.


Surgical Repair/Removal/Specimen Collection: The hernia sac is reduced, and a large piece of mesh is

placed to cover the indirect, direct and femoral areas of the inguinal region. The mesh is held in place by metal staples or pigtail corkscrews.


Hemostasis and Irrigation: The extraperitoneal space is examined for

any possible bleeding and irrigated thoroughly with normal saline.

All bleeding is controlled with a cautery-capable endo-instrument.

All the instruments and ports should be carefully and slowly removed while the O/2 is released.


Closure: Closure will be surgeon specific. Some


Other surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin.

Skin staples are always an option.


Major Arteries: Inferior epigastric artery The testicular artery arises from the anterior aspect of the

aorta at the level of L2 vertebrae. This is the main artery supplying the testis and the

epididymis. The artery of the ductus deferens is a slender vessel that

arises from the inferior vesical artery. It accompanies the ductus deferens throughout its course

and anastomoses with the testicular artery near the testis. The cremasteric artery is a small vessel that arises from the

inferior epigastric artery. It supplies the cremaster muscle and other coverings of the spermatic cord.


Major Veins: Inferior epigastric vein: the vein that drains into the

external iliac vein and arises from the superior epigastric vein. Along its course, it is accompanied by a similarly named artery, the inferior epigastric artery.

Major Nerves: Femoral nerve:

• one of a pair of nerves that originate from lumbar nerves and supply the muscles and skin of the anterior part of the thigh

http://upload.wikimedia.org/wikipedia/commons/e/ef/Gray1036.png


http://www.njsurgery.com/html/Procedures/lapahern.htmlhttp://www.aafp.org/afp/990101ap/143.htmlhttp://en.wikipedia.org/wiki/Inguinal_hernia

http://www.njsurgery.com/html/Procedures/lapahern.html

http://www.aafp.org/afp/990101ap/143.html

http://en.wikipedia.org/wiki/Inguinal_hernia

http://en.wikipedia.org/wiki/Inguinal_hernia

Open Herniorrhaphy

Overall Purpose of Procedure: Hernias present as bulges in the groin area that can become more

prominent when coughing, straining, or standing up. They are often painful, and the bulge commonly disappears on lying down. The inability to "reduce", or place the bulge back into the abdomen usually means the hernia is "incarcerated," often necessitating emergency surgery.

As the hernia progresses, contents of the abdominal cavity, such as the intestines, can descend into the hernia and run the risk of being pinched within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine caught in the hernia is compromised, the hernia is deemed "strangulated," and gut ischemia and gangrene can result, with potentially fatal consequences.

Open Herniorrhaphy

Define the procedure: repair strength to the inguinal floor and to prevent abdominal tissue from reentering the inguinal canal.

Wound Classification: 1Case length – 30 mins to 2 hours.

Open Herniorrhaphy

1- Incision2- Hemostasis3- Dissection 4- Exposure5- Procedure (Specimen Collection possible)6- Hemostasis 7- Irrigation8- Closure9- Dressing Application

Open Herniorrhaphy

Instrumentation: Minor/Major Instrument Tray.

What basic instruments will you expect to see in this tray?

Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient. Trendelenburg? WHY?

Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from navel to mid thigh and all of groin area and far lateral on both sides. Pre-prep hair trimming might be necessary.

Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.

Open Herniorrhaphy

Incision: McBurneys incision

Which one isthe McBurney?

Open Herniorrhaphy

Hemostasis: Handheld Bovie, hemostats, free ties or clips are utilized.

Open Herniorrhaphy

Dissection and Exposure:

Metz scissors and Debakey forceps.

Bovie for dissection and hemostasis

Army-Navy Ret, Small Rich or even Goulet for retraction and exposure of surgical site.

Dissection is deepened into the subcutaneous fat where two veins, the superficial epigastric and the superficial external pudendal should be divided with ligatures while smaller vessels can be bovied.

http://upload.wikimedia.org/wikipedia/commons/4/43/Gray549.png

Open Herniorrhaphy

Exploration and Isolation:

The inguinal canal is opened along the line of the fibers of the external oblique aponeurosis extending the incision into the superficial ring.

If an indirect sac is present, it is now dissected free from the cord structures which are safeguarded and retracted

Open Herniorrhaphy

Surgical Repair/Removal/Specimen Collection: The site is then prepared

for mesh. The full length of the

inguinal ligament should be exposed.

Align the mesh so that tension is not placed on the surrounding tissue.

Open Herniorrhaphy

Surgical Repair/Removal/Specimen Collection: Three or four interrupted

sutures are used to fix the mesh superiorly. The two tails are now overlapped lateral to the deep ring and secured by two or three interrupted sutures making sure that the cord is not constricted.

Open Herniorrhaphy

Hemostasis and Irrigation: All bleeding is controlled with a cautery. Use of warm Saline to irrigate.

Open Herniorrhaphy

Closure: Surgeons will use a 0-Vicryl to close the

fascial/muscle layer and a 4-0 Monocryl for skin.

Skin staples are always an option.


Laparoscopic Nissen Fundoplication


• Overall Purpose of Procedure:– Nissen fundoplication is a procedure that alleviates chronic

heartburn (Gastroesophageal reflux disease (GERD)) in people whose condition cannot be controlled by either lifestyle changes or medication. Their symptoms are caused by severe gastroesophageal reflux due to a weak valve muscle between the stomach and the esophagus. They experience a burning sensation from the chest to the throat whenever stomach acids are forced back up into the esophagus.


• Define the procedure: Preventing stomach acids from being forced back into the esophagus by wrapping the upper portion of the stomach, or fundus, around the bottom of the esophagus with the aid of a laparoscope and laparoscopic instruments to strengthens the stomach valve.

• Wound Classification: 2• Case length –2 to 4 hours.

Laparoscopic Nissen Fundoplication• Instrumentation: Laparoscopic Instrument Tray. • What other basic instruments will you expect to see in this tray?• Always have Major Bowel tray and large retractors (Balfour/Bookwalter) in the room. • Have Long Bowel Inst. in room. • Have multiple endo-staplers and reloads available.• Have Maloney/Bougie dilators available ALWAYS!

• Positioning: The patient is in supine position, arms tucked or on arm boards/padded. Surgeon stands on the left side of the patient with the camera holder/assistant on opposite side of bed. Monitor should be placed near right hip facing towards surgeon. Reverse Trendelenburg? WHY?



Laparoscopic Nissen Fundoplication Begin your Operative Sequence

• Incision: Two towel clips around umbilicus.– 15 kb on #3 handle

for incision.– Veres Needle and

CO-2 on high flow.


cont. Operative Sequence• Hemostasis: Can be from multiple means. The

pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.

Laparoscopic Nissen Fundoplication cont. Operative Sequence

• Dissection and Exposure:– Multiple ports ( x 5 to start)– Three 10-mm and two 5-mm

trocars are inserted.– The laparoscope is introduced

through a port placed in the midline superior to the umbilicus. Placing the 5-mm trocars on either side of the midline allows for triangulation and avoids interference with the camera’s line of vision.


• Dissection and Exposure:– The procedure begins with

the exposure of the esophageal hiatus by the anterior retraction of the left lateral segment of the liver with a fan retractor. The liver is elevated and the stomach is exposed.


• Exploration and Isolation:– Circumferential blunt

dissection of the esophagus at the level of the hiatus will allow for the anterior retraction of the esophagus


• Surgical Repair:

– The fundus of the stomach is brought behind the esophagus and sutured to itself.

– This anterior segment is approximated over the esophagus to the posterior fundus to ensure a snug wrap, which can be measured over a 56 Fr Maloney/ Bougie or by experience. A maneuver is used to ensure that the fundus slides freely posterior to the esophagus and is of appropriate length.


• Surgical Repair:– the intra-abdominal portion

of the lower esophageal sphincter is enhanced and reflux into the esophagus is greatly reduced.

– Close attention is paid not to incarcerate the Anterior Vagus Nerve (controls peristalsis in the esophagus)


• Hemostasis and Irrigation:– The intra-abdominal cavity is irrigated thoroughly with

normal saline.– All bleeding is controlled with a cautery-capable endo-

instrument of Surgeons choice.– Special attention is focused on the liver bed. Highly

vascularized area.– The abdomen should be examined for any possible

bowel injury or hemorrhage. All instruments and ports should be carefully and slowly removed while the CO-2 in the pneumoperitineum is released.


• Closure:– Closure will be surgeon specific. Some


– Other surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin.

– Skin staples are always an option.

Results

• In properly selected patients, the surgery is successful in improving or eliminating heartburn and regurgitation in greater than 90% of patients.

Results

• Patients notice improvement in direct symptoms such as heartburn and regurgitation immediately after surgery. Indirect symptoms such as asthma, hoarseness, dysphagia, cough, globus, and esophageal spasm often take weeks to months to improve. These symptoms are not as reliably improved after surgery as the direct symptoms of GERD. Indirect symptoms also do not respond as well to medical treatment.

Results

• In most patients this result is durable and lasting with multiple studies showing a high degree of patient satisfaction many years after the procedure.


• Major Arteries:– The Left Gastric Artery – The Right Gastric Artery – The Left Gastro-omental Artery – The Right Gastro-omental Artery – The Short Gastric Arteries – The Gastroduodenal artery. – The Splenic artery. – The Common Hepatic artery


• Major Veins: The right gastro-omental vein drains into the superior mesenteric vein, and then into the portal vein.

• The left gastro-omental vein drains into the splenic vein and then into the portal vein.

• The left and right gastric veins drain into the portal vein

directly. • Major Nerves: Anterior Vagus nerve• The greater and lesser splanchnic nerves and left phrenic

nerve.

Video

• Laparoscopic Nissen Fundoplication - YouTube

• Laparoscopic Nissen Fundoplication EES EDU

http://www.youtube.com/watch?v=cdWrx1NQRTE

http://www.youtube.com/watch?v=cdWrx1NQRTE




http://www.lapsurgery.com/nissen.htmhttp://www.ctsnet.org/sections/clinicalresources/thoracic/freeman.htmlhttp://www.medscape.com/viewarticle/535591http://crlsurgical.com/surgical/fundoplication.php

http://www.lapsurgery.com/nissen.htm

http://www.ctsnet.org/sections/clinicalresources/thoracic/freeman.html

http://www.medscape.com/viewarticle/535591

http://crlsurgical.com/surgical/fundoplication.php

Hemorrhoidectomy


Hemorrhoidectomy• Overall Purpose of Procedure:

• This is a procedure to remove dilated veins of the anus and rectum.

Hemorrhoidectomy• Define the procedure:

• Incisions are made in the tissue around the hemorrhoid. The swollen vein inside the hemorrhoid is tied off to prevent bleeding, and the hemorrhoid is removed.

• Hemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse.

• Hemorrhoids are either inside the anus—internal—or under the skin around the anus—external.

• Wound Classification: 2• Case length – 30 mins to 1 hour

Operative Sequence• 1- Incision• 2- Hemostasis• 3- Dissection • 4- Exposure• 5- Procedure (Specimen Collection

possible)• 6- Hemostasis • 7- Irrigation• 8- Closure• 9- Dressing Application

Hemorrhoidectomy• Instrumentation: Major/Minor Instrument tray a possibility.

Hemorrhoidectomy tray a definite• Positioning: The patient is in Kraske or Lithotomy position. If

Lithotomy position, arms tucked at the side or on arm boards. If Kraske, arm out on arm boards by head. Surgeon stands on the left side of the patient.

• Prepping: Surgeon preference. Hibiclense or a Betadine Prep Kit. Buttocks will be held apart with adhesive and tape.

• Prep from buttocks to groin area prepping anus last. Pay close attention to pooling of prep around genitailia.


Hemorrhoidectomy Begin your Operative Sequence

• Incision: 10 kb or 15 kb on #3 handle for incision.

Hemorrhoidectomy cont. Operative Sequence

• Hemostasis: Handheld Bovie, hemostats, free ties are utilized.

• Note: no alcohol based prep to be used if the surgeon will using the ESU.


• Dissection and Exposure:• Surgeon will

use hand dilation, then might use a rectal dilator or semi-elliptical rectal retractor.


• Exploration and Isolation: pre-op” anoscopy or sigmoidoscopy is a possibility.• Are either of these a sterile procedure?


• Surgical Repair/Removal/Specimen Collection:• Hemorrhoid is grasped with a clamp of

surgeon preference.• Have Pennington, Kocher, or Allison

clamp available.• The hemorrhoid is ligated from the

surrounding tissue• To ligate the vessel, the surgeon will

throw a 2-0 or 3-0 Chromic suture.

Hemorrhoidectomy Alternative

• Stapled hemorrhoidectomy: • In stapled hemorrhoidectomy,

following four-finger anal dilation, the surgeon places a purse-string suture in the rectal mucosa and sub-mucosa about 2 cm above the hemorrhoids.

• A circular stapler, for a one-time use at a cost of roughly $350, is then inserted into the anus.

Hemorrhoidectomy Alternative

• The purse-string suture is drawn tight, bringing redundant rectal mucosa and some hemorrhoidal tissue into the stapler head. The device is then fired, stapling the prolapse while circumferentially resecting a chunk of rectal mucosa, which is then removed.

• This chunk is called a “donut”• You or the surgeon must make sure the

donut is complete in it’s circularity.


• Hemostasis and Irrigation:• All bleeding is controlled with cautery

or suture. • Use of warm Saline to irrigate.


• Closure:• The Anal mucosa may be left open or

loosely sutured.• Anus is packed with gauze

impregnated with antibiotics.

Hemorrhoidectomy• Major Arteries:• Aorta• Middle rectal artery

• The middle rectal artery is an artery in the pelvis that supplies blood to the rectum.

• Hemorrhoidal Arteries

http://upload.wikimedia.org/wikipedia/en/9/97/Midrectal.png

Hemorrhoidectomy• Major Veins:

• rectal venous plexus:

• Major Nerves: • rectal plexus: vascular

smooth muscle of the pelvic viscera, especially the rectum

• inferior rectal: external anal sphincter and provides sensation to the skin of the anus

Colectomy/Colostomy


Colectomy• Overall Purpose of Procedure:

– Surgery during which all or part of the colon (also called the large intestine) is removed for reasons such as:• Cancer• Diverticulitis • Intestinal obstruction • Ulcerative colitis • Traumatic injuries • Pre-cancerous polyps

Colectomy• Define the procedure:

– A colectomy is surgical removal of the colon, or large intestine. If only part of the colon is removed, the procedure is called a hemicolectomy.

• Wound Classification: 2• Case length – 1 to 3 hours.

Colectomy• Instrumentation: Major Instrument tray. Long Abdominal tray. Abdominal

Retractors, Bookwalter etc.

• Positioning: The patient is in supine position. Arms out on arm boards or tucked. Surgeon stands on the left side of the patient.



Colectomy Begin your Operative Sequence


• Midline incision

Colectomy cont. Operative Sequence

• Hemostasis: Handheld Bovie, hemostats, free ties or hemoclips are utilized.


• Dissection and Exposure:– Metz scissors and Debakey

forceps.– Bovie– Army-Navy Ret, Small Rich or

even Goulet for retraction and exposure of superficial site.

– Deaver or Harrington retractor for deeper retraction.

– Possible need of Bookwalter Ret.


• Exploration and Isolation:– The colon is retracted and freed.– Large retractors are put into place.


• Surgical Repair/Removal/Specimen Collection:

• The section of the colon that is to be removed is located.– The mesentery is clamped and ligated.– The omentum is ligated.– All ligation is accomplished with Kelly clamps or hemostats, Metz

scissors and either ties or suture or Bovie.

Colectomy • Surgical Repair/Removal/Specimen

Collection:– Complete mobilization of the bowel to be removed is

a must.– Atraumatic graspers are placed across the bowel to

either side of the section of the bowel that is to be resected.

– Staplers can be used for this part of the procedure as well.

Colectomy

• Surgical Repair/Removal/Specimen Collection:– An end to end anastomosis is performed using a two

layer suturing technique (mucosa/serosa) with suture or a stapler may be used.

– Possible Colostomy at this stage –stoma is created.

Colostomy

• Colostomy incision is made well away from the original midline incision to place the “stoma” away from incision site to reduce possible contamination of wound.

• A colostomy is a surgical procedure that brings a portion of the large intestine through the abdominal wall to carry feces out of the body.

Colostomy• Temporary colostomies are created to divert stool from injured or

diseased portions of the large intestine, allowing rest and healing. • Permanent colostomies are performed when the distal bowel must be

removed or is blocked and inoperable. Although colorectal cancer is the most common indication for a permanent colostomy, only about 10–15% of patients with this diagnosis require a colostomy.

Colostomy

• 3 types:– End colostomy. The functioning end of the intestine (the

section of bowel that remains connected to the upper gastrointestinal tract) is brought out onto the surface of the abdomen, forming the stoma (artificial opening) by cuffing the intestine back on itself and suturing the end to the skin. The surface of the stoma is actually the lining of the intestine, usually appearing moist and pink. The distal portion of bowel (now connected only to the rectum) may be removed, or sutured closed and left in the abdomen. An end colostomy is usually a permanent ostomy, resulting from trauma, cancer, or another pathological condition.

Colostomy

• Double-barrel colostomy. This involves the creation of two separate stomas on the abdominal wall. The proximal (nearest) stoma is the functional end that is connected to the upper gastrointestinal tract and will drain stool; the distal stoma, connected to the rectum and also called a mucous fistula, drains small amounts of mucus material. This is most often a temporary colostomy performed to rest an area of bowel, and to be later closed.

Colostomy

• Loop colostomy. This surgery brings a loop of bowel through an incision in the abdominal wall. The loop is held in place outside the abdomen by a plastic rod slipped beneath it. An incision is made in the bowel to allow the passage of stool through the loop colostomy. The supporting rod is removed approximately seven to 10 days after surgery, when healing has occurred that will prevent the loop of bowel from retracting into the abdomen. A loop colostomy is most often performed for creation of a temporary stoma to divert stool away from an area of intestine that has been blocked or ruptured.

Colostomy

– Remember that instruments that come into contact with the INTERIOR of bowel are considered contaminated and need to be kept separate form other clean/sterile instruments.

– Remove them from your immediate field and make sure you don’t go back to them (even when you count!).

Colectomy/ Colostomy cont. Operative Sequence

• Hemostasis and Irrigation:– All bleeding is controlled with cautery or

suture. – Use of warm Saline to irrigate.

Colectomy/ Colostomy cont. Operative Sequence

• Closure:– Will use strong suture for peritoneal layer such

as 0 looped PDS.– Will use a 0-Vicryl to close the fascial/muscle

layer and a 4-0 Monocryl for skin. – Skin staples are always an option.– Will need a ostomy kit for stoma.

Colectomy/ Colostomy

• Major Arteries:– superior mesenteric

arteries.

Colectomy/ Colostomy

• Major Veins: – superior mesenteric

vein

• Major Nerves: – superior mesenteric ganglia.

Modified Radical

Mastectomy


Modified Radical Mastectomy

• Overall Purpose of Procedure:• The purpose for modified radical mastectomy is the removal of breast cancer.• Modified radical mastectomy is the most widely used surgical procedure to treat operable breast

cancer. This procedure leaves a chest muscle called the pectoralis major intact. Leaving this muscle in place will provide a soft tissue covering over the chest wall and a normal-appearing junction of the shoulder with the anterior (front) chest wall. This sparing of the pectoralis major muscle will avoid a disfiguring hollow defect below the clavicle. Additionally, the purpose of modified radical mastectomy is to allow for the option of breast reconstruction, a procedure that is possible, if desired, due to intact muscles around the shoulder of the affected side. The modified radical mastectomy procedure involves removal of large multiple tumor growths located underneath the nipple and cancer cells on the breast margins.


• Define the procedure: • In a modified radical

mastectomy, the entire breast is removed, including the skin, areola and nipple, as well as some to most of the lymph nodes under the arm.

Other Types• Simple mastectomy (or "total mastectomy"): In this

procedure, the entire breast tissue is removed, but axillary contents are undisturbed. Sometimes the "sentinel lymph node"--that is, the first axillary lymph node is removed.

• Radical mastectomy (or "Halsted mastectomy"): this procedure involves removing the entire breast, the axillary lymph nodes, and the pectoralis major and minor muscles behind the breast. This procedure is more disfiguring than a modified radical mastectomy and provides no survival benefit for most tumors. This operation is now reserved for tumors involving the pectoralis major muscle or recurrent breast cancer involving the chest wall.

Other Types cont.

Lumpectomy - surgery to remove the tumor and a small amount of normal tissue around it

Radical Mastectomy


• Wound Classification: 1

• Case length – 1 to 2 hours. Greatly depends on anatomy.

Modified Radical Mastectomy• Instrumentation: Major/Minor Instrument Tray. • What basic instruments will you expect to see in this tray? • What other instruments might you need?

• Positioning: The patient is in supine position, arms on arm boards. Surgeon stands on the affected side of the patient.

• Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from chin to midchest area and far lateral on affected side, sometimes including the arm and axillia.

• Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips. Might have to cover arm/hand with Coban and Stockinette.

Modified Radical Mastectomy Begin your Operative Sequence


• Surgeon will trace the incision line and the area for the skin flaps with the marking pen.

• An incision in the shape of an ellipse is made.

Modified Radical Mastectomy cont. Operative Sequence



• Dissection and Exposure:• The skin flaps are raised to

the previously marked lines and retracted with:

• Lahey Thyroid Tenaculums

• Kochers etc.


• Exploration and Isolation:• Skin flaps are made carefully and as thinly as

possible to maximize removal of diseased breast tissues.


• Surgical Repair/Removal/Specimen Collection:

• The skin over a neighboring muscle (pectoralis major fascia) is removed, after which the surgeon focuses in the armpit (axilla, axillary) region. In this region, the surgeon carefully identifies vital anatomical structures such as blood vessels (axillary vein) and nerves. Accidental injury to specific nerves like the medial pectoral neurovascular bundle will result in destruction of the muscles that this surgery attempts to preserve, such as the pectoralis major muscle. In the armpit region, the surgeon carefully protects the vital structures while removing cancerous tissues. After axillary surgery, breast reconstruction can be performed, if desired by the patient.

Mastectomy specimen containing a very large cancer of the breast (in this case, an invasive ductal carcinoma)


• Hemostasis and Irrigation:• All bleeding is controlled with cautery. • Use of warm Saline to irrigate.


• Closure:• Will place 2 small drains in the axilla.• The pectoralis muscles are sutured together with a

strong Vicryl.• Skin is closed with surgeons choice of suture or staples.

Modified Radical Mastectomy• Major Arteries:

• The breast is supplied with blood from the internal mammary artery, the axillary artery and the intercostal arteries, which run around the breast near the skin surface.

Modified Radical Mastectomy• Major Veins:

• Blood drains from the breast by a network of veins, returning to the axillary, internal mammary and intercostal veins

• Major Nerves: thoracic • Intercostal nerves T3-T5

Go to next slide!• How hard can this case be?• We have talked about this as an average case. • Average anatomy, average time frame of 1 to 2

hours, average instrumentation and so on.• As with all cases, what considerations would you

have to make if you were presented with the following……..

Considerations?

Breast prostheses used by some mastectomy patients

General Procedures

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