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General Surgical Operations
Dhiraj Choudhury
SECTION ONE: GENERAL PRINCIPLES
1:
Indications and Classifications of Operation
INDICATIONS
Absolute Indications
Relative Indications
CLASSIFICATIONS
2:
Preparations for Operation
PREOPERATIVE PREPARATIONS OF THE PATIENT
Assessment of Fitness
Admission
Clinical Assessment
Routine Investigations
Preoperative Directions
Special Preparations
PREPARATIONS OF THE OPERATING TEAM SCRUB-UP TECHNIQUE
Entry to Operation Theater
Scrubbing
Gowning
Gloving
3:
An Operation: Step by Step
POSITION OF PATIENT
Supine Position
Lateral Position
Lithotomy Position
Trendelenburg's Position
Lioyd-Davis Position
Prone Position
Jack-Knife Prone Position
ANESTHESIA
SKIN PREPARATION AND DRAPPING
POSITION OF SURGEON
INCISION
Method of Making Incision
EXPOSURE
PROCEDURES
CLOSURE
4:
Methods of Hemostasis in Surgery
TOURNIQUET
FLUID INFILTRATION
DIATHERMY
LASER
HARMONIC SCALPEL SYSTEM
PRESSURE
CLIPPING, LIGATION AND UNDER RUNNING
Hemostatic Clips
LOCAL HEMOSTATS
5:
Knots and Sutures in Surgery
SUTURE AND LIGATURE MATERIALS
SURGICAL KNOTS
Type of Knots (Table 5.1)
Granny Knot
Reef Knot
Triple-throw Knot
Surgeon's Knot
Aberdeen Knot
Methods of Tying Knots
By Both Hands
By One Hand
By Instrument
LAPAROSCOPIC KNOT-TYING
METHODS OF SUTURING
Simple Interrupted Suturing
Continuous Suturing
Continuous Locked Suturing
Mattress Suturing
Subcuticular Suturing
6:
Role of Surgical Drains
INDICATIONS
TYPES (FIG. 6.1)
Open Drains
Corrugated Rubber or Silastic Sheet
Closed Drains
Rubber Tube Drain
Silicon Tube Drain
Penrose Drain
Closed Suction Drain
Sump Drain
Percutaneous Drainage
FIXATION OF DRAINS
REMOVAL OF DRAIN
7:
Techniques of Achieving Skin Cover
DIRECT CLOSURE BY SUTURING
SKIN GRAFTING Indications
Types
Free Skin Graft
Partial Thickness/Split Graft/Thiersch Graft
OPERATIVE PROCEDURE
Anesthesia
Local
General
Preparation of Donor Site
Graft Cutting
Graft Treatment
Graft Application
Graft Fixation
Dressing of Donor Site
Full-thickness (Wolfe) Graft
Pinch Grafts
FLAPS
Indications
Types
Random Pattern Flaps
Axial Flaps
Myocutaneous Flaps
TISSUE EXPANSION
8:
Principles of Minimal Access Surgery/Minimally Invasive Surgery
NATURE OF MINIMAL ACCESS/MINIMALLY INVASIVE SURGERY
SCOPES OF MINIMAL ACCESS/INVASIVE SURGERY
ADVANTAGES
DISADVANTAGES
FUNDAMENTALS OF LAPARO (INSIDE) SCOPIC (TO SEE) SURGERY
Indications
Diagnostic
Therapeutic
Contraindications
Absolute
Relative
Operation Room Setup
Equipments
Hand Instruments
Operative Procedure
Anesthesia
OT Setup and Patient Position
Operative Technique
Problems
Operative Complications and its Avoiding
SECTION TWO: HEAD AND NECK
9:
Burr Hole Procedures
INTRODUCTION
HISTORY
PROCEDURE
Sites of Placement
INDICATIONS AND PRESENT USAGE
Therapeutic Indications
Diagnostic Indications
Craniotomy Flaps (Fig. 9.4)
Chronic Subdural Collections (Fig. 9.5)
Aspiration of Brain Abscess
Stereotactic Procedures
CSF Diversion Procedures
Neuroendoscopic and Functional Neurosurgical Procedures
Monitoring of Intracranial Pressure
Ultrasound Navigation
Exploratory Burr Holes
Positions (Fig 9.7)
Choice of Initial Burr Hole
Rate of Positivity
RISKS OF BURR HOLES
CLOSURE OF BURR HOLES
CONCLUSION
10:
Cervical Lymph Node Biopsy
INDICATIONS
ANATOMY
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURES
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
11:
Surgery for Parotid Tumors
SUPERFICIAL PAROTIDECTOMY
Indication
Preoperative Preparation
Anesthesia
Position of Patient/Draping
Incision
Procedure
Complications
EXCISION OF DEEP LOBE PAROTID TUMORS
FOLLOW-UP/RESULTS OF TREATMENT
12:
Simple Lithotomy for Submandibular Duct Stone
INDICATION
OPERATIVE PROCEDURE
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATION
13:
Excision of Submandibular Salivary Gland
ANATOMY
INDICATIONS
PREOPERATIVE PREPARATION
OPERATIVE PROCEDURE
Position
Anesthesia
Draping
Incision
Exposure
Mobilization of Superficial Lobe (Fig. 13.4)
Ligation of Facial Artery at Lower Border
Ligation of Facial Artery at Upper Border (Figs 13.7A and B)
Mobilization of the Deep Lobe
Division of the Duct (Fig. 13.9)
Closure
RADICAL EXCISION
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATION
14:
Operations for Cancer of the Oral Tongue
INTRODUCTION
Staging of Carcinoma of the Tongue
CHOICE OF TREATMENT FOR T1 AND T2 LESIONS
ANESTHESIA AND OTHER PRELIMINARY STEPS
HEMIGLOSSECTOMY FOR T1, T2 LESIONS
Anatomical Basis for the Operation
Operative Steps
Incisions
Division of Nerve and Artery
Closure
Postoperative Care
Complications
SURGERY FOR T3 LESIONS
GLOSSECTOMY WITH EXCISION OF FLOOR MOUTH
15:
Neck Dissections
INTRODUCTION
INDICATIONS AND CONTRAINDICATIONS
LEVELS OF LYMPH NODES
VARIANTS OF NECK DISSECTION— DEFINITIONS
Radical Neck Dissection (RND)
Elective or Prophylactic Neck Dissection
Partial Neck Dissections
Supraomohyoid Neck Dissection
ANESTHESIA AND POSITION OF THE PATIENT
OPERATIVE STEPS FOR MND TYPE 1 (XI NERVE SPARING PROCEDURE)
Choice of Skin Incision
STEP BY STEP OPERATIVE PROCEDURE
RADICAL NECK DISSECTION
POSTOPERATIVE CARE
INTRAOPERATIVE PROBLEMS
POSTOPERATIVE COMPLICATIONS
SUPRAOMOHYOID NECK DISSECTION
HISTOPATHOLOGICAL EXAMINATION
16:
Commando Operation
INDICATION
PREOPERATIVE PREPARATION
ANESTHESIA
POSITION/DRAPING
INCISION
PROCEDURE
COMPLICATIONS
17:
Surgery for Thyroid Cancer
INTRODUCTION
SURGICAL ANATOMY
Musculofascial Coverings
Vascular Anatomy
The Superior Vascular Pedicle
The Inferior Thyroid Artery
The Inferior Thyroid Veins
The Middle Thyroid Vein
The Thyroidea Ima Artery
Important Close Surgical Relations of the Thyroid Gland
The External Laryngeal Nerve
The Recurrent Laryngeal Nerves
The Parathyroid Glands
The Lymphatics
TYPES OF THYROID OPERATIONS
PREOPERATIVE PREPARATION
PREOPERATIVE WORK-UP
THYROIDECTOMY TECHNIQUE
Positioning of the Patient
Incision
Management of Strap Muscles
Initial Mobilization of Gland
Identification of the Recurrent Laryngeal Nerve
Localization and Preservation of the Parathyroid Glands
Mobilization of Superior and Inferior Pole of Thyroid
Final Mobilization of the Gland
SPECIAL POINTS FOR THYROIDECTOMY IN CANCER
POSTOPERATIVE COMPLICATIONS
18:
Subtotal Thyroidectomy
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
19:
Excision of Thyroglossal Cyst and Fistula
EXCISION OF THYROGLOSSAL CYST
Indications
Operative Procedure
EXCISION OF THYROGLOSSAL FISTULA
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATION
20:
Excision of Branchial Cyst and Fistula
ANATOMY
Indications
Preoperative Step
Operative Procedure
EXCISION OF BRANCHIAL FISTULA
Postoperative Care
Postoperative Complications
21:
Tracheostomy
INDICATIONS
Upper Airway Obstruction
Prolonged Ventilatory Support
Preoperative Steps
PREOPERATIVE PROCEDURE
Position
Emergency Procedure
Elective Procedure
Postoperative Care
Postoperative Complications
SECTION THREE: THE BREAST
22:
Operation for Benign Breast Lesions
INCISION AND DRAINAGE OF BREAST ABSCESS
Indication
Preoperative Preparation
Operative Procedure
EXCISION OF FIBROADENOMA OF BREAST
Indications
Operative Procedure
Postoperative Care
Postoperative Complication
EXCISION OF GIANT FIBROADENOMA
Operative Procedure
EXCISION OF DUCTS
Excision of Single Duct Microdochectomy
Indication
Excision of Major Duct System: Hadfield's Operation
Indications
Operative Procedure
EXICISION OF GYNECOMASTIA
Indications
Operative Procedure
Postoperative Care
Postoperative Complications
23:
Surgery in Breast Cancer
INTRODUCTION
Anatomy of the Normal Breast
Surgery in Breast Cancer
Introduction
Contraindications to Breast Conservation Surgery
SURGERY IN BREAST CANCER
Excision Biopsy
Needle Localization Biopsy
Breast Conservation Surgery
Histopathological Evaluation
Modified Radical Mastectomy
Radical Mastectomy
Simple Mastectomy
Microdochectomy
POSTOPERATIVE CARE
BREAST RECONSTRUCTION
SECTION FOUR: THE ESOPHAGUS
24:
Open Esophagocardiomyotomy: Heller's Operation
INDICATION
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE: TRANSABDOMINAL
POSTOPERATIVE CARE
COMPLICATIONS
Intraoperative
Postoperative
25:
Nissen Fundoplications: Open Method
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
Early
Late
26:
Laparoscopic Repair of Gastroesophageal Reflux and Hiatus Hernia
INDICATIONS
AIMS OF OPERATION
PREOPERATIVE PREPARATION
OPERATIVE PROCEDURE
Anesthesia
Patient Position
Trocar Position (Fig. 26.1)
Technique of Nissen Fundoplication
Dissection of the Crura (Figs 26.5A to D)
Fundic Mobilization (Figs 26.6 A to C)
Crural Closure
Fundoplication (Figs 26.8A to D)
Laparoscopic Partial Fundoplication
POSTOPERATIVE CARE
COMPLICATIONS
27:
Laparoscopic Esophageal Myotomy
PNEUMATIC DILATATION
INTRASPHINCTERIC INJECTION OF BOTULINUM TOXIN
SURGICAL METHODS
Open Surgery
Minimally Invasive Surgery
PREOPERATIVE PREPARATION
OPERATIVE PROCEDURE
Anesthesia
Patient Positioning and Room Setup
Trocar Position
The Hiatal Dissection
The Myotomy
Antireflux Procedure
Dorprocedure
POSTOPERATIVE CARE
COMPLICATIONS
28:
Surgery for Carcinoma of the Esophagus
TNM STAGING
INVESTIGATIONS
Diagnostic Investigations
Staging Investigations
TREATMENT OPTIONS
Two Factors Determine the Treatment
Surgical Approaches
Transthoracic Esophagectomy with Cervical Anastomosis
Anesthesia
Thoracotomy
Esophageal Mobilization
Lymph Node Dissection
Abdomen
Gastric Mobilization
Lymph Node Dissection
Gastric Tube
Conduit Route
Neck
Infraomohyoid Neck Dissection
Ivor-Lewis Procedure
Operative Steps
Abdomen
Thorax
Anastomosis
Transhiatal Esophagectomy
Indications and Patient Selection
Anesthesia
Procedure
Gastric Mobilization
Cervical Dissection
Transhiatal Esophageal Dissection
Anastomosis
Esophagogastrectomy Through Left Thoracoabdominal (Garlock) Approach
Indications and Patient Selection
Anesthesia
Procedure
POSTOPERATIVE CARE AND COMPLICATIONS
SECTION FIVE: THE ABDOMEN: GENERAL
29:
Abdominal Incisions and Closure
VERTICAL INCISIONS
Mid-line Incisions
Upper Mid-line Incision (Fig. 29.1A)
Steps
Lower Mid-line Incision (Fig. 29.1B)
Paramedian Incision (Figs 29.1C and D)
Steps
Rectus Splitting
OBLIQUE INCISIONS
Kocher's Sub-costal Incision (Fig. 29.5A)
Steps
Roof-Top (Bilateral Subcostal) Incisions (Figs 29.5A and B)
Steps
McBurny's Gridiron Incision (Fig. 29.5C)
Steps
Rutherford-Morrison Incision (Fig. 29.5D)
Steps
TRANSVERSE INCISIONS
Upper Transverse Incision (Fig. 29.6A)
Steps
Lanz Transverse Incision (Fig. 29.6B)
Steps
Pfannelstiel Incision (Fig. 29.6C)
Steps
Thoraco-abdominal Incision
Indications
Steps
CLOSURE OF ABDOMINAL WOUNDS
Mass Closure
Layered Closure
All Layers Closure
30:
Intestinal Anastomosis
METHODS: SEW OR STAPLE
HAND SEWN METHODS
End-to-End Anastomosis: Between Two Mobile Segments
End-to-end Anastomosis: Between Mobile and Fixed Segments
Techniques
End-to-side Anastomosis
Side-to-side Anastomosis
STAPLED ANASTOMOSIS
31:
Intestinal Stomas
GASTROSTOMY
Indication
Percutaneous Endoscopic Gastrostomy
Steps
Stamm Gastrostomy
Steps
FEEDING JEJUNOSTOMY
Indications
Methods
Witzel Method
Recent Methods
LOOP ILEOSTOMY
Indication
Operative Procedure
Formation of Loop Ileostomy
Closure of Loop Ileostomy
END ILEOSTOMY
Indication
Procedure
COLOSTOMY
Indications
Types
Loop Colostomy
Steps of Transverse Colostomy (Loop)
Pelvic (Loop) Colostomy
Operative Procedure
End/Terminal Colostomy
OTHER STOMAS
Cecostomy
Paul-Mikulicz Type
Closure of Colostomy
Preoperative
Methods
Complications of Colostomy
32:
Laparotomy for Abdominal Trauma
INDICATIONS OF LAPAROTOMY
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE: LAPAROTOMY
MANAGEMENT OF SPECIFIC INJURIES
Diaphragm
Liver
Major Liver Injuries: Gross Lacerations, Vena Caval Injuries
Gallbladder and Extrahepatic Biliary Track
Spleen
Conservative Treatment
Operative: Splenectomy
Splenorrhaphy
Stomach
Duodenum
Classification
Options for Treatment of Duodenal Rupture or Perforation
Closure
Diversion
Indications
Pyloric Exclusion with Gastrojejunostomy
33:
Laparotomy for Intestinal Obstruction
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Decompression of Bowel
Irrigation of Bowel
MANAGEMENT OF SPECIFIC CAUSES
Bands
Adhesionlysis
Noble's Plication
Stricture
Strangulated (Nonviable) Small Bowel
Intussusception
Volvulus
Malignant Obstruction
CLOSURE
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
SECTION SIX: THE STOMACH DUODENUM
34:
Pyloromyotomy: Ramstedt's Operation
INDICATION
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
OPERATIVE TECHNIQUE
CLOSURE
POSTOPERATIVE CARE
35:
Vagotomy
TRUNCAL VAGOTOMY
Indications
Preoperative Preparations
Operative Procedure
Technique of Truncal Vagotomy
Mobilization of Esophagus
Anterior (Left) Truncal Vagotomy (Fig. 35.4)
Posterior (Right) Truncal Vagotomy (Fig. 35.5)
Difficulties
Closure
PROXIMAL GASTRIC VAGOTOMY: HIGHLY SELECTIVE VAGOTOMY
Operative Procedure
Exposure
Identification of Right and Left Vagal Trunks
Identification of Crow's Foot
Dissection of Anterior Nerve of Latarjet (Fig. 35.6)
Dissection of Posterior Nerve of Latarjet(Fig. 35.7)
Closure
Postoperative Care
Postoperative Complications
36:
Pyloroplasty: Heineke-Mikulicz
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Kocherization of Duodenum
Pyloroduodenal Incision
Closure
FINNEY PYLOROPLASTY
Closure of Abdomen
Postoperative Care
Complications
37:
Gastrojejunostomy
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE: POSTERIOR GASTROJEJUNOSTOMY: POSTERIOR, RETRO-COLIC, OBLIQUE ISO-PERISTALTIC ANASTOMOSIS
Anastomotic Technique
First Layer
Second Layer
Third Layer
Fourth Layer
Closure
ANTERIOR GASTROJEJUNOSTOMY
38:
Operation for Perforated Peptic Ulcer
INDICATION
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Exploration
Peritoneal Toilet
Identification of Site of Perforation
Simple Closure of Perforation
Omentoplasty
Other Procedures
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
39:
Operation for Bleeding Peptic Ulcer
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Exposure
Technique
Pyloro-duodenotomy
Under-running
Pyloroplasty
Truncal Vagotomy
Bleeding Gastric Ulcer
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
40:
Radical Gastrectomy
RADICAL TOTAL GASTRECTOMY
Indications
Anesthesia
Position
Incision
Procedure
DISTAL RADICAL GASTRECTOMY
Indications
Anesthesia
Position
Incision
Procedure
Reconstruction
PROXIMAL RADICAL GASTRECTOMY WITH PARTIAL ESOPHAGECTOMY
Indications
Anesthesia
Patient Position
Incision
Procedure
Reconstruction
SECTION SEVEN: HEPATOBILIARY
41:
Operative Drainage of Subphrenic Abscess
ANATOMY OF SUBPHRENIC SPACES (FIG. 41.1)
INDICATIONS
OPERATIVE PROCEDURES
Anterior Extraperitoneal Approach
Posterior Sub-pleural Approach
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
42:
Open Cholecystectomy
ANATOMY
INDICATIONS OF OPEN CHOLECYSTECTOMY
PREOPERATIVE STEPS
OPERATIVE PROCEDURE
Exposure
Procedure
Neck First Method
Fundus First Method
Intraoperative Problems
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
43:
Laparoscopic Cholecystectomy
INTRODUCTION
INDICATIONS
PERIOPERATIVE MANAGEMENT
OPERATIVE TECHNIQUE PNEUMOPERITONEUM
HAND INSTRUMENTS (FIG. 43.1)
OPERATIVE TECHNIQUE
Pneumoperitoneum
Placement of Ports
Placement of First Port (Umbilical Port)
Placement of Accessory Ports
Introduction of Hand Instruments (Figs 43.10 and 43.11)
Adhesiolysis (Fig. 43.14)
Dissection of Calot's Triangle (Fig. 43.15)
Posterior Dissection (Figs 43.16 and 43.17)
Isolation of Cystic Ducts and Cystic Artery (Figs 43.18 to 43.23) and Application of Clips
Intraoperative Cholangiography
Securing Cystic Duct
Risk Factors for Bile Duct Injury
Mobilization and Removal of Gallbladder
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
SUBTOTAL CHOLECYSTECTOMY AND “FUNDUS-FIRST” APPROACH
Suspected GB Cancer
CONCLUSION
44:
Surgery of Bile Duct
ANATOMY
DUCTAL ANOMALIES
SURGERY OF BILE DUCT STONES
Choledocholithotomy
Steps of Choledocholithotomy
Note on Operative Cholangiogram
Technique
Biliary Drainage Procedure
Transduodenal Sphincterotomy/ Sphincteroplasty
Technique of Sphincterotomy/Sphincteroplasty (Figs 44.1 to 44.3)
Complications
Choledochoduodenostomy (Figs 44.4 to 44.6)
Complications
BILE DUCT INJURIES
MANAGEMENT OF BILE DUCT INJURIES
When Detected During Surgery
Treatment of Complications Detected during Postoperative Period
Bile Collections and Peritonitis
External Biliary Fistula
Biliary Stricture (Fig. 44.7)
Results of Biliary Reconstruction Procedures
Surgery of Choledochal Cysts in Adults
Resection of Choledochal Cyst
Complications of the Operation
SECTION EIGHT: PANCREAS
45:
Surgery of Pancreas
SURGERY FOR ACUTE PANCREATITIS
Introduction
Indications of Surgery
Infected Pancreatic Necrosis
Pancreatic Abscess
Preoperative Preparations
Operating Procedure
Incision
Exposure
Operative Technique
Summary of Problems Faced during Necrosectomy
Closure
Postoperative Care
Postoperative Complications
PANCREATICOJEJUNOSTOMY
Introduction
Indication
Preparations
Operative Procedures
Technique: First Part: Exposure of Duct and Lithotomy (Fig. 45.1)
Technique: Second Part: Anastomosis
Closure
Postoperative Care
Postoperative Complications
PSEUDOCYST OF PANCREAS
Indications
Preoperative Preparations
Operative Procedure: (Transgastric Cystogastrostomy or Roux-en-Y (Cysto-jejunostomy)
Exposure
Techniques (Fig. 45.5)
Closure
Postoperative Care
Postoperative Complications
PANCREATICODUODENECTOMY
Introduction
Indication
Preparations
Judging Operability
Minimizing Jaundice
Preparations for Jaundice
Operative Procedures
Exposure
Technique: First Part: Resection (Fig. 45.7)
Technique: Second Part: Reconstruction (Fig. 45.8)
Closure
Postoperative Care
Postoperative Complications—Several
SECTION NINE: SPLEEN
46:
Surgery of Spleen
ANATOMY OF SPLEEN
SPLENECTOMY Indications
Indications
Preoperative Preparations
Operative Procedure
Emergency Splenectomy
Elective Splenectomy
Closure
Postoperative Care
Postoperative Complications
SECTION TEN: SMALL BOWEL
47:
Operations on Small Bowel
SMALL BOWEL RESECTION AND ANASTOMOSIS
Indications
Operative Procedure
Technique
STRICTUROPLASTY
Indications
THE ROUX-EN-Y LOOP
Advantages
MECKLE'S DIVERTICULECTOMY
Indications
Operative Procedure
ILEOSTOMY
SECTION ELEVEN: APPENDIX
48:
Appendicectomy Open Method
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Delivery of Appendix
Dealing with Appendicular Artery
Ligations of Appendicular Stump
Closure
SPECIAL PROBLEMS
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
Early
Late
49:
Laparoscopic Appendicectomy
HISTORY
INDICATIONS
CONTRAINDICATIONS
STEPS OF OPERATION
Steps
Identification of Cecum and Diagnostic Laparoscopy
Displaying the Whole Appendix (Fig. 49.3)
Lysis of Mesoappendix
Amputation of the Appendix
Extraction of the Appendix
The Final Look (Fig. 49.5)
Optional Extra Maneuvers
POTENTIAL ADVANTAGES OF LAPAROSCOPIC APPENDICECTOMY
LAPAROSCOPIC APPENDICECTOMY IN PREGNANCY
SUGGESTED PRINCIPLES
WHAT TO DO IF THE APPENDIX APPEARS NORMAL?
SPECIAL SITUATIONS
Retrograde Laparoscopic Appendicectomy
Submucosal Appendicectomy
Two Port Appendicectomy
Single Port Appendicectomy
CURRENT STATUS OF LAPAROSCOPIC APPENDICECTOMY
COMPLICATIONS OF LAPAROSCOPIC APPENDICECTOMY
SECTION TWELVE: LARGE BOWEL
50:
Colectomy
INTRODUCTION
SURGICAL ANATOMY
INDICATIONS
SPECIAL PREPARATION
Right Hemicolectomy
Indications
Access and Anesthesia
Assessment
Mobilization of Right CoIon (Fig. 50.3)
Division of the Vessels (Fig. 50.5)
Excision of Segment
Restoration of Continuity
Final Check
Drain
Closure
Extended Right Hemicolectomy
Indications
Conservative Right Hemicolectomy
Indications
Left Hemicolectomy
Indications
Mobilization of Left Colon
Division of Blood Vessels
Radical Excision of Left Colon
Indications
Procedure
Sigmoid Colectomy
Indications
Procedure
Total Colectomy
POSTOPERATIVE CARE
COMPLICATIONS
FURTHER CARE
51:
Total Colectomy with Mucosal Proctectomy and Ileal Pouch-anal Anastomosis
INTRODUCTION
INDICATIONS
PREOPERATIVE PREPARATION
OPERATIVE PROCEDURE
General Principles
Incision
Total Colectomy and Proctectomy
Construction of the Ileal Pouch
Mucosectomy
Ileoanal Anastomosis
Closure
POSTOPERATIVE CARE
COMPLICATIONS AND THEIR MANAGEMENT
Early Complications
Late Complications
52:
Sub-total Colectomy with Ileorectal Anastomosis, Ileostomy and Mucous Fistula
INTRODUCTION
EMERGENCY SURGERY
Colectomy with Ileostomy
Operative Procedure
Mucus Fistula/Closure of Rectal Stump
Length of Rectosigmoid Stump
Elective Surgery
Indications
Which Operation?
Subtotal Colectomy with Ileorectal Anastomosis
Technique
Anastomosis (Figs 52.3 to 52.5)
53:
Operations for Diverticular Disease
SURGICAL MANAGEMENT OF DIVERTICULAR DISEASE
MANAGEMENT OF ACUTE DIVERTICULITIS
MANAGEMENT OF COLONIC OBSTRUCTION
MANAGEMENT OF MASSIVE COLONIC HEMORRHAGE
MANAGEMENT OF COLOVESICAL FISTULA
PRIMARY RESECTION AND ANASTOMOSIS
Operative Strategy
Properative Preparation
Operative Procedure
Incision
Dissection of the Sigmoid and Left Colon
Division of Mesocolon
Anastomosis
Abdominal Closure
Hartmann's Procedure
Laparoscopically Assisted Reversal of Hartmann's Procedure
Surgical Technique
54:
Synchronous Combined Abdominoperineal Resection (APR) of Rectum
INTRODUCTION
Indications
Preoperative Preparations
OPERATIVE PROCEDURE
Anesthesia
Position (Fig. 54.2)
Abdominal Part (Fig. 54.4)
Incision and Exposure (Fig. 54.5)
Assessment of Operability and Resectibility
Mobilization of Colon (Fig. 54.6)
Ligation of Pedicle (Figs 54.9 and 54.10)
Pelvic Dissection and Total Mesorectal Excision (Figs 54.11 and 54.12)
Division of Colon (Fig. 54.13)
Closure of Abdomen
Construction of Colostomy (Fig. 54.14)
Perineal Dissection
Incision (Fig. 54.15)
Dissection (Fig. 54.16)
Removal of Coccyx
Division of Iliococcygeus Muscles
Exposure of Mesorectum
Anterior Dissection
Lateral Dissection
Removal of the Specimen
Closure of Perineal Wound (Fig. 54.17)
Extent of Anterior Dissection in Females
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
55:
Sphincter Saving Operations for Rectal Cancer
INTRODUCTION
SPHINCTER SAVING OPERATIONS FOR RECTAL CANCER
High Anterior Resection of Rectum
Hand Sutured Anastomosis (Figs 55.5 to 55.8)
Stapled Anastomosis (Figs 55.9A to E)
Testing Integrity of the Anastomosis
Pitfalls
Low Anterior Resection
Closure
TRANSANAL EXCISION OF RECTAL CANCER
Criteria for Selection
Operative Procedure
56:
Palliative Procedures for Rectal Cancer
HARTMANN'S OPERATION
Indication
Operative Procedure
Technique
COLOSTOMY
ELECTROCOAGULATION
CRYOTHERAPY
LASER THERAPY
57:
Operations for Rectal Prolapse
ABDOMINAL PROCEDURES
Indication
Preoperative Preparation
Operative Procedure: Wells Procedure: Rectal Fixation
Mobilization of Sigmoid Colon and Rectum
Rectopexy
Ripsteine Procedure
PERINEAL PROCEDURES
Thiersh Operation
Procedure
Technique
Delormes Procedure
Technique
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATION
SECTION THIRTEEN: ANAL AND PERIANAL
58:
Surgery for Hemorrhoids
HEMORRHOIDECTOMY—OPEN METHOD/ MILLIGAN MORGAN METHOD
Indication
Preoperative Preparations
Operative Procedure
Postoperative Care
Postoperative Complications
MINIMALLY INVASIVE PROCEDURE FOR HEMORRHOIDS (MIPH)
59:
Surgical Procedures for Anal Fissure
ANAL STRETCHING
Procedure
Postoperative Care
LATERAL INTERNAL SPHINCTEROTOMY
Operative Procedure: Open Method
Technique
Closure
CLOSED LATERAL INTERNAL SPHINCTEROTOMY
Fissurectomy with Dorsal Sphincterotomy
Postoperative Care
60:
Incision and Drainage of Anorectal Abscess
OPERATIVE PROCEDURE: INCISION AND DRAINAGE
Perianal and Ischiorectal Abscess
Technique
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
61:
Operation for Fistula in Ano
LOW FISTULA
Preoperative Preparations
Operative Procedure
Procedure
Technique
Closure
Operative Procedure for Horse-shoe Fistula
Endo-rectal Advancement Flap Repair
Postoperative Care
Postoperative Complications
SECTION FOURTEEN: HERNIAS
62:
Operation for Epigastric Hernia
INDICATION
OPERATIVE PROCEDURE
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
63:
Operation for Umbilical Hernia in Infants and Children
INDICATION
OPERATIVE PROCEDURE
64:
Operation for Adult Umbilical Hernia or Paraumbilical Hernia
INDICATION
PREOPERATIVE STEPS
OPERATIVE PROCEDURE
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
65:
Operation for Incisional Hernia: Open Method
INDICATION
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Repair
Simple Anatomical Repair
Complex Anatomical Repair
Repair by Proline Mesh
Onlay Patch Repair
Extraperitoneal Mesh Repair: Rives Stoppa Techniques
Intraperitoneal Mesh Repair
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
66:
Operation for Inguinal (Groin) Hernias: Open Method
GENERAL PRINCIPLES
TYPES OF REPAIR
Tension Repair/Pure Tissue Repair
Tension Free Repair
INGUINAL HERNIOTOMY IN INFANTS AND CHILDREN
Operative Procedure
Exposure
Dissection of the Cord
Isolation of the Sac
Herniotomy
Repair
Closure
HERNIA REPAIR: PROCEDURES IN ADULTS
Preoperative Preparations
Operative Procedure
Incision
Exposure
Dissection of the Cord (Fig. 66.8)
Dissection of the Sac
Dealing with the Sac
Repair
Pure Tissue Repairs
Additions and Alterations of Bassini Method
Tension-free Repair
Plug and Patch Repair
Three-dimensional Mesh Repair
Postoperative Care
Postoperative Complications
STRANGULATED HERNIA
Preoperative Preparations
Salient Steps
Dealing with Sac
Repair
Closure
Postoperative Care
Postoperative Complications
Concluding Remarks
67:
Operations for Femoral Hernia
SURGICAL ANATOMY
INDICATION FOR OPERATION
OPERATIVE PROCEDURE
Approaches
Low Approach
Pre-peritoneal Approach: McEvedy
High Approach-Lothisen
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
68:
Inguinal Hernia: Laparoscopic Repair
INTRODUCTION
ANATOMY
CONVENTIONAL ANATOMY
Laparoscopic Anatomy
Triangle of Doom
Triangle of Pain
LAPAROSCOPIC HERNIOPLASTY
Transabdominal Preperitoneal Hernioplasty (TAPP)
Operative Technique
Extraperitoneal Approach
Operative Technique
POSTOPERATIVE MANAGEMENT
CONCLUSION
SECTION FIFTEEN: GENITOURINARY
69:
Nephrectomy
ANATOMY
SURGICAL APPROACHES TO KIDNEY
Posterolateral Approach
11th or 12th Rib Approach
Nagamatsus Thoraco-lumbar Approach
Anterior Transperitoneal Approach
INDICATIONS
OPERATIVE PROCEDURE: SIMPLE NEPHRECTOMY
Anesthesia
Position
Incision for Posterolateral Approach
Exposure
Dealing with Renal Pedicle (Fig. 69.7)
Closure
RADICAL NEPHRECTOMY
Operative Technique: Transabdominal Approach
Right Sided Nephrectomy
Dealing with Venacaval Involvement
Left Sided Nephrectomy
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
70:
Open Surgery for Renal Calculi
INDICATION
PROCEDURE
Technique
Pyelolithotomy
Extended Pyelolithotomy
Nephrolithotomy
Pyelo-nephrolithotomy
Nephrectomy
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
71:
Pyeloplasty: Anderson-Hynes
INDICATION
OPERATIVE PROCEDURE
Approach
Technique
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
72:
Operation for Ureteric Stones
ANATOMY
OPEN URETEROLITHOTOMY
Indication
Preoperative Preparation
Operative Procedure
Stone in the Upper Third of Ureter
Stone in the Middle Third of Ureter
Stone in Lower third of Ureter
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
73:
Total Radical Cystectomy
INDICATION
AIMS
PREOPERATIVE CARE
OPERATIVE PROCEDURE
Procedure
Ligation of Internal Iliac Artery
Transection of Ureters
Mobilization of Bladder
Dealing with Membranous Urethra
Urinary Diversion
Pelvic Lymphadenectomy
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
Immediate
Late
74:
Meatotomy Meatoplasty
INDICATION
OPERATIVE PROCEDURE
Technique
Meatotomy
Meatoplasty
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
75:
Circumcision
INDICATION
OPERATIVE PROCEDURE IN CHILDREN
Guillotine Method
OPERATIVE PROCEDURE IN ADULT
Dorsal Slit Technique/Dissection Method
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
76:
Amputation of Penis
INDICATIONS
OPERATIVE PROCEDURE
Partial Amputation of Penis
Exposure and Technique
Fashioning of Urethral Opening
Total Amputation of Penis
Exposure
Closure
Fashioning Urethrostomy
Dealing with Inguinal Lymph Nodes
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATION
77:
Orchiopexy
INDICATIONS
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Problem
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
78:
Orchidectomy
SIMPLE ORCHIDECTOMY
Indications
Operative Procedure
RADICAL ORCHIDECTOMY
Indication
Operative Procedure
SUBCAPSULAR ORCHIDECTOMY
Indication
Procedure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
79:
Operation for Hydrocele
INDICATIONS FOR OPERATION
PREOPERATIVE PREPARATIONS
OPERATIVE PROCEDURE
Eversion of Sac (Jabouly's Operation)
Technique
Eversion of Sac (Fig. 79.4)
Hydrocelectomy
Lord's Plication
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
80:
Vasectomy
INDICATION
PREOPERATIVE PREPARATION
OPERATIVE PROCEDURE
No Scalpel Vasectomy
Advantages
Disadvantages
Steps
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
81:
Varicocelectomy
INDICATIONS
OPERATIVE PROCEDURE
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
SECTION SIXTEEN: VASCULAR SURGERY
82:
Exposure of Major Peripheral Arteries
INDICATIONS
Emergency
Elective
COMMON CAROTID ARTERY
Indications
Operative Procedure
Closure
EXTERNAL AND INTERNAL CAROTID ARTERIES
Operative Procedure
SUBCLAVIAN ARTERY
Indications
Operative Procedure
AXILLARY ARTERY
Indications
Operative Procedure
BRACHIAL ARTERY
In-Arm
Operative Procedure
In Cubital Fossa
RADIAL ARTERY
Operative Procedure
FEMORAL ARTERY
Indications
Operative Procedure
In Hunter's Canal
POPLITEAL ARTERY
Indications
Operative Procedure
83:
Operations for Arterial Injuries
TYPES OF INJURIES
Arterial Hematoma
TYPES OF REPAIR
Operative Procedure
Exposure of Artery
Technique
Direct Repair
Vein Patch Graft
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATION
84:
Femoral Embolectomy
INDICATION
PREOPERATIVE STEPS
OPERATIVE PROCEDURE
Procedure: Embolectomy (Fig. 84.1)
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
85:
Operations for Varicose Veins
TREATMENT OPTIONS FOR VARICOSE VEINS
Conservative Method
Indications
Injection Method
Indications
Operative Methods
Indications
Types of Operations
TRENDELENBURG'S OPERATION: JUXTA-FEMORAL FLUSH LIGATION
HIGH LIGATION OF THE LONG SAPHENOUS VEIN
STRIPPING OF LONG SAPHENOUS VEIN
Steps
Problem
Closure
Compression Bandage
SAPHENOPOPLITEAL LIGATION AND STRIPPING
Operative Procedure
AVULSIONS OR MULTIPLE PHLEBECTOMY
Operative Procedure
SUB-FASCIAL LIGATION (COCKET AND DODD'S)
Operative Procedure
POSTOPERATIVE COMPLICATIONS
POSTOPERATIVE CARE
86:
Sympathectomy
CERVICODORSAL SYMPATHECTOMY
Indications
Preoperative Preparations
Approaches
ANTERIOR SUPRACLAVICULAR APPROACH
Technique
Closure
Postoperative Care
Postoperative Complication
AXILLARY APPROACH
Technique
Closure
TRANSTHORACIC ENDOSCOPIC SYMPATHECTOMY
Preoperative Preparation
Procedure
LUMBAR SYMPATHECTOMY
Indications
Preoperative Preparations
EXTRAPERITONEAL APPROACH
Exposure
Technique
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
87:
Lower Limb Amputations
BELOW-KNEE AMPUTATION
Indications
Preoperative Preparations
Operative Steps
Incision
Technique
Closure
ABOVE KNEE AMPUTATION
Indications
Preoperative Preparations
Operative Procedure
Incision
Technique
Closure
POSTOPERATIVE CARE
POSTOPERATIVE COMPLICATIONS
INDEX
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