Chapter 14 Flashcards
General Surgery
What organs does general surgery typically deal with?
-Esophagus
-Stomach
-Small/Large Intestine
-Appendix
-Rectum
-Spleen
-Pancreas
-Liver and Biliary System
-Hernias (inguinal, umbilical, ventral, incisional, diaphragmatic)
-Thyroid/parathyroid
-Breast
-Lymphatic
What is included in the major laparotomy set (Major Set)?
-Poole suction tip (1)
-6, 8, 10” DeBakey Forceps (2)
-Straight Mayo Scissors (1)
-Curved Mayo Scissors (1)
-7 and 9” Metz (1)
-Ferris-Smith Forceps (2)
-Adson w Teeth (2)
-Adson Brown (2)
-Russian Forceps (2)
-Cushing Brain Forceps (2)
-Curved Mosquitoes (6)
-Straight Kellys 5.5” (6)
-Curved Kellys 5.5” (6)
-8” Pean (6)
-6.25 Kocher (4)
-Curved Mixter Forceps (2)
-Bacchus (4)
-Forester Sponge Stick (2)
-6, 8, 10.5” Mayo Needle Holder (2)
-Green Loop Retractor (2)
-Goulet Retractor (2)
-Army Navy Retractor (2)
-0.75, 1.25” Ribbon Retractor (1)
-1, 2” Deaver Retractors (1)
-Small Richardson Retractor (2)
-Large Richardson Retractor (1)
-2.5” Kelly Retractor (1)
-Gelpi Retractor (1)
-Weitlaner (1)
-Balfour Retractor and Blades (1)
-Harrington Retractor (3)
-6, 10” Allis (4)
-6.25, 9.25” Babcock (2)
-Pennington Clamp (2)
-7.5” Tonsil Forceps (4)
What are “long and deep” instruments?
Refers to instruments that are longer than normal for use in deep cavities or bariatric surgery.
What is the general rule of thumb for general surgery when entering the abd?
A major set is required (may vary on surgeon preference, facility, and region.
What are intestinal instruments?
Instruments that are designed to be atraumatic for minimal tissue damage and to promote healing. Include bowel clamps, stapling devices (linear, circular), circular suturing devices, extra forceps, and Poole suction. May be included in expanded major set
What are minor sets used for?
Used for minor procedures (breast bx, inguinal hernia). Additional instruments are added for more complex surgeries.
What is included in a minor set?
-#3 Knife Handles (2)
-Straight mayo scissors (1)
-Curved mayo scissors (1)
-7” metz (1)
-Adson w teeth (2)
-6” DeBakey forceps (2)
-Curved mosquitoes (6)
-Curved kellys (6)
-Bacchus clamps (6)
-6” mayo needle holder (2)
-7” mayo needle holder (2)
-Army navy retractors (2)
-6” Allis (2)
-6.25” Babcock (2)
-5.5” Probe w eye (1)
-5.5” Grooved director w probed tip (1)
-Senn retrator (2)
-Small Richardson (2)
-3 Prong Rake Retractor (2)
-Frazier suction tip (1)
-Tonsil Clamps (4)
What are biliary instruments?
Used to explore the common bile duct and removing caliculi. Include ductal forceps and stone “scoops”.
What are some unique instruments for specific procedures?
-Adair tenaculums for large breast masses
-Ligature carriers to pass sutures in tight spaces
-Maloney esophageal dilators
-Liver retractors
-Vein stripper for removal of varicose veins
-Thyroidectomy set
-Tracheotomy set
-Rectal set that includes anoscope, rectal speculum, rectal dilators, Buie pile forceps
-Laparoscopic instrumentation including curved and hook scissors, L and J hooks, curved and straight grasping clamps, babcock and intestinal clamps, retractors of various types and sizes, needle holders, claws, laparoscopes, camera, light cord, and insufflation tubing for Veress needle, trocars and sheaths, and laparoscopic kitners
-Vascular set (repair of liver laceration; splenectomy).
-Thoracotomy set (repair of liver laceration; trauma).
What is some routine equipment for general surgery procedures?
-ESU w grounding pad and foot pedal
-Harmonic scalpel and LigaSure
-Suction apparatus
-Headlamp
-Laser
-Cell-Saver
-Hypo-/hyperthermia unit
-Forced-air warming devices
-Intermittent venous compression device and boots (bariatric patients; patients prone to DVT)
-Patient positioning devices
-Bariatric patient OR beds
What equipment is used for laparoscopic procedures?
-Video tower (includes monitor, insufflator, video camera processing unit, light source, printer for still photography, video recording device)
-“Slave” monitor
-Carbon dioxide source
What are some routine supplies used for general surgery?
-Skin prep set
-Back table pack (usually laparotomy basic pack)
-Laparoscopy supplies (e.g., trocars, insufflation tubing, Veress needle, scope warmer, antifog solution, endobag)
-Basin set
-Sterile gloves
-Knife blades (commonly #10 and #15; laparoscopic procedures need #11)
-ESU active electrode
-Bovie pencil extended tip
-Bipolar cord for attachment to laparoscopic instrumentation (activated with foot pedal of ESU)
-Stapling devices (frequently a staple cart with most commonly used staplers) for open and laparoscopic surgical procedures
-Synthetic mesh for hernia repairs
-Suture
-Sponges (e.g., 4 × 4’s; laparotomy sponges)
-Sterile dressing material
-Foley catheter
-Additional towels, gloves, gowns, and sponges available for cases involving contact with the inside of the alimentary canal
What factors determine the type of incision?
-access desired
-procedure
-surgeon preference
-ability to lengthen the incision
-wound security/healing
-pt physical condition
-speed of entry required
-sites of previous surgery.
What are some components of a vertical median incision?
Use: to access any organ in the abd, ventral herniorrhaphy, and trauma.
Advantages: good access, can be extended, rapid entry into abd, and least hemorrhagic.
Disadvantages: Wide scar formation and increased risk of herniation and desinence.
Types: Epigastric, subumbilical, and full midline (curving around the umbilicus and extending from a point below the xiphoid to a point above the symphysis pubis)
Opening Technique: skin and subq are cut over the linea alba, small vessels are coagulated, linea alba and fat are cut until the peritoneum, petironeum is then entered at the point closest to the umbilicus to avoid injury to the bladder and falciform ligament.
Closing Technique: Peritoneum is closed w continuous 2-0 absorbable suture (can be closed w fascia), Fascia is closed w 0/1 nonabsorbable interrupted suture, Skin is closed w 4-0 nylon, subcuticular sutures or skin staples.
Variations:
-the entire thickness of the wound may be closed in one layer called through and through
What are some components of the vertical paramedian incision?
Use: to access any organ in the abd, ventral herniorrhaphy, left lower is good for sigmoid surgery
Advantages: better wound strength than median, cosmesis, lower incident of herniation
Disadvantages: increased intraop bleeding, infection rates, postop pain, nerve damage, and atrophy of rectus abdominus
Types: upper, lower, and lateral (junction of the middle and outer thirds of the rectus sheath)
Opening Technique: Skin and subq are cut to anterior rectus sheath, Anterior rectus is dissected away from the muscle, Rectus muscle is retracted laterally, Posterior rectus sheath and peritoneum are cut in the same plane as the anterior sheath.
Closing Technique: Peritoneum and posterior rectus sheath are closed w2-0 or 0 absorbable suture, anterior sheath closed w 0 absorbable or nonabsorbable, subcutaneous tissue approximated with interrupted plain gut, chromic, or similar suture, skin is closed as in median incision.
What are some components of an Oblique Incision—Kocher Subcostal?
Use: Biliary tract (right) and spleen (left)
Opening Technique: Incision begins at midline 2.5–5 cm below xiphoid and extends obliquely lateral 12 cm, staying 2.5 cm below the costal margin, rectus sheath and muscle are divided with the ESU, underlying lateral musculature is incised in outward direction for a short distance and retracted to expose the peritoneum, the small eighth dorsal nerve may be divided; however, the ninth dorsal nerve must be preserved to prevent weakening of the abdominal musculature, and peritoneum is incised the length of the incision.
Closing Technique: Peritoneum and fascia are closed with 0 synthetic absorbable or nonabsorbable suture, subcutaneous tissue may be approximated with 2-0 absorbable suture, and skin is closed with interrupted nylon subcuticularly, or with staples.
What are some components of a transverse incision?
Use: Curved transverse upper abdominal incision is for access to the pancreas and abdominal exploration for blunt trauma;
lower transverse incision used for access to pelvic viscera
Advantages: Access to specific organs and strong closure
Disadvantages: Hemorrhagic, muscle splitting, and may endanger nerves
Types: Upper transverse (a bilateral subcostal incision that is joined through the midline) and lower transverse
Opening Technique: Upper transverse is incised bilaterally as described in the subcostal incision, and joined at the midline
Closing Technique: Peritoneum and fascia are closed with 0 absorbable or nonabsorbable suture, Subcutaneous tissue may be approximated w 2-0 absorbable suture, and skin is closed w nylon suture, subcuticularly, or with staples
What are some components of the thoracoabdominal incision?
Use: Converts pleural and peritoneal spaces into one cavity; used when access is required esophagogastric surgery (left) or emergency hepatic resection (right)
Advantages: Access to specific organs and access to both pleural and peritoneal spaces
Disadvantages: Difficult patient positioning, wide scar formation and increased risk of herniation and desinence, requires chest tube, and
difficult for patient postoperatively
Opening Technique: Incision begins as standard midline or left upper paramedian, extended obliquely over the thorax along the eighth costal interspace, diaphragm is divided radially toward the esophageal hiatus
Closing Technique: Begins with repair of diaphragm w #1 silk, chest tube is placed in ninth intercostal space along posterior axillary line, standard closure of the chest, standard median or paramedian closure.
What is a laparotomy?
Surgical opening through the skin layer and abdominal wall into the peritoneal cavity
When is a laparotomy used?
Many procedures in the peritoneal cavity (bowel) begin with a laparotomy opening or when surgeon is unsure of diagnosis an exploratory laparotomy is used to explore pathology.
What are the layers of the abdominal wall?
-Skin
-Subcuticular
-Subcutaneous fat
-Scarpa’s fascia
-External oblique muscle
-Internal oblique muscle
-Transversus abdominus muscle
-Transversalis fascia
-Peritoneum
What equipment/instrument sets should be used for a laparotomy?
-Major laparotomy set
-Self-retaining retractor
What supplies should be gathered for a laparotomy?
Laparotomy back table pack
What is the preop preparation for a laparotomy?
-Pt positioned in supine
-General anesthesia is used
-Skin is prepped from mid-chest to the pubic symphysis laterally as far as possible; may be extended to mid-thigh for extensive procedures
-Laparotomy drape is used and towels are used to square off
What are some practical considerations for a laparotomy?
-Have Yankauer and Poole suction tips available. When using the Poole in the abd, surgeon may want to wrap a wet lap sponge around the tip to prevent tissue attaching
-Surgeon may irrigate the abd cavity with an antibiotic solution mixed by CST at the back table in a graduated pitcher or bowl.
-Variety of retractors will be needed
What is the opening procedure for a laparotomy?
- Midline skin incision is made and extended around the umbilicus. (Place lap sponges on each side of incision. Skin knife used. Have ESU and forceps ready)
- Incision is deepened. (Deep knife used. As surgeon goes deeper, deeper retractors will be used.
- Bleeding vessels are clamped ligated or cauterized. (Keep ESU cautery blade clean)
- Using curved mayos, ESU, or scalpel, external oblique is opened the length of the skin incision-muscle splitting incision bc incision is in direction of fibers. (Keep clean laps on field)
- Medium retractors are placed to retract the external obliques (Richardsons)
- Internal obliques, transverse muscle, and transversalis fascia are split in the direction of muscle fibers up to the rectus sheath using scalpel or curved mayos, medium retractors are replaced with large Richardsons w longer blades to retract the internal oblique and transverse muscle.
- Peritoneum is exposed. Small incision is made using smooth forceps to grasp/ elevate to prevent underlying bowel from being injured (Surgeon may prefer hemostat instead of forceps)
- If abnormal fluid is encountered, sponges and suction are used as needed. Cultures will also be taken if necessary (Instruments/suction tips that come into contact w infectious fluid are contaminated and should not be used when closing)
- Edges of peritoneum and transversalis fascia are grasped w Kocher on each lateral edge and slight traction is placed laterally.
- Using metz, curved mayos, or scalpel, peritoneal incision is lengthened. The surgeon may insert the index and middle finger beneath the peritoneum to aid in elevating it and cut the tissue between the two fingers in the direction of the pelvis.
- One or two vessels in fatty layer between fascia and peritoneum in the region of the umbilicus will need to be quickly clamped and ligated.
- Richardsons are repositioned to allow surgeon to explore
- Once affected, nonaffected, and anatomical landmarks are identified, Richardsons will be replaced with a large self-retaining retractor
What is the closing procedure for a laparotomy?
- Peritoneum is closed. (Counts should be completed before closure)
If closed independently: edges of transversalis fascia is grasped w toothed forceps to expose peritoneum and edges of peritoneum are grasped with clamps. The clamps are crossed to bring edges together. Synthetic absorbable suture in continuous or interrupted fashion can be used. A medium ribbon retractor may be placed under peritoneal layer to keep the underlying organs pushed away from the suture line to avoid being sutured to the peritoneum. Internal oblique fascia is then closed with absorbable or nonabsorbable sutures in continuous/interrupted fashion.
If closed in a single unit w fascia: heavy looped synthetic absorbable or nonabsorbable suture is used, #0 or #1 size; it is usually placed in continuous fashion. - Muscle may be sutured.
- External oblique fascia and Scarpa’s fascia are separately closed w interrupted 3-0 absorbable sutures. (Smaller instruments are used as the wound becomes more superficial)
- 3-0 or 4-0 absorbable, interrupted sutures in the subcuticular layer.
- Skin could be closed by
-edges being approximated by tooth forceps and sutured w 3-0, 4-0 silk or nylon on a cutting needle
-Subq is closed w interrupted/continuous 3-0, 4-0, or 5-0 synthetic absorbable/nonabsorbable sutures.
-Skin staples are often used to approximate the skin edges.
What are some postop considerations for a laparotomy?
Accoding to procedure, pt is transported to PACU. Complications, wound healing/classification, and prognosis depends on pt condition, pathology that required surgery, and procedure performed.
What are the four main categories of esophageal pathology?
- hiatal hernia/reflux esophagitis
- esophageal motility disorders
- neoplasms
- trauma
What are some components of esophageal hiatal hernia?
S&Sx: Acid reflux, mucosal erosion/ulceration/scarring, stricture, burning pain, pain is positional
Dx: history, fluoroscopy while swallowing barium, endoscopy, and manometry
Tx: medications that reduce acid production/reflux, diet/sleeping modifications, correction of anatomical defect, valve reconstruction in lower esophagus, and therapeutic endoscopy.
What are some components of esophageal motility disorders?
S&Sx: dysphagia, regurgitation of undigested food
Dx: x-ray w contrast medium and cineradiography
Tx: meds and endoscopic dilation
What are some components of Achalasia?
S&Sx: weight loss, pain, aspiration pneumonia
Dx: Manometry
Tx: therapeutic endoscopy and transection of muscle
What are some components of esophageal diverticula (Zenker’s)?
S&Sx: regurgitation of recently swallowed material, choking, foul breath
Dx: x-ray w contrast
Tx: excision of diverticula and correction of cause
What are some components of esophageal Neoplasm?
S&Sx: Dysphasia, weight loss, pain
Dx: barium contrast study and CT scan
Tx: radiotherapy, tracheostomy, extirpation of esophagus, and reconstruction
What are some components of esophageal trauma?
S&Sx: ingestion of caustic substance and perforation
Dx: varies
Tx: imediate intervention
What is a Laparoscopic Nissen Fundoplication?
surgical procedure that corrects a hiatal hernia
What is the surgical anatomy and physiology of the lower esophagus?
Abdominal esophagus extends from the esophageal hiatus to the opening of the cardia of the stomach. Abdominal esophagus lies in the esophageal groove on the posterior surface of the left lobe of the liver. At the point where it joins the stomach is a layer of circular muscle fibers called the lower esophageal sphincter (LES), which contracts to close the opening to the stomach and prevent food and gastric juices from reentering the esophagus. Hiatal hernia occurs when the esophageal hiatus is weak, which allows the abdominal esophagus and superior portion of the stomach to protrude into the thoracic cavity.
What are some instruments and equipment that is unique to a laparoscopic nissen fundoplication?
-Harmonic scalpel
-Laparoscopic equipment
-Insufflator
-Laparoscopy instrumentation and laparoscopes
-Liver retractor (fan retractor)
-Coagulation hook
-Grasping forceps
-Laparoscopic ligating clip w clips
-Trocars: 10 mm × 3; 5 mm × 2
-Minor instrument set
-Laparotomy instrument set with additional long instrumentation (available for conversion from laparoscopic to open procedure)
What are some supplies that are unique to a laparoscopic nissen fundoplication?
-Maloney dilators
-#11 and #15 knife blades
-Laparoscopy supplies
What is the preop preparation for a laparoscopic nissen fundoplication?
-pt is positioned in supine w thighs slightly abducted and flexed or in 20 degrees Trendelenburg and in low stirrup
-general anesthesia is used
-skin is prepped from nipple line to mid-thighs and laterally as far as possible
-Draping: Apply leggings if stirrups are used; square off with four towels–edge of upper towel placed mid-chest; lateral towels placed using anterior superior iliac spines as guide; edge of lower towel placed just above line of sympysis pubis; abdominal laparoscopic drape
What are some practical considerations for a laparoscopic nissen fundoplication?
-X-rays and barium studies in OR
-Check all equipment
-Surgeon usually stands between the patient’s legs, surgical assistant on the patient’s left, and the surgical technologist on patient’s right
-Be prepared for conversion from laparoscopic to open procedure if complications arise
What are the steps for a laparoscopic nissen fundoplication?
- 5 Trocars are placed above the umbilicus, R and L subcostal, between the umbilicus and L subcostal, and under the xyphoid process. A 30 deg laparoscope is placed in the periumbilical port. (Order of trocars is 10 mm, 5 mm, 5 mm, 10 mm, 10 mm)
- CST retracts L lobe of liver exposing esophageal hiatus
- Lesser omentum is opened and R pillar of hiatus is identified. Extragastric vagal branches might be sacrificed. (Have laparoscopic scissors, coagulation hook, and ligating clips ready)
- Incision is made in peritoneum and phrenoesophageal ligament is severed (Have grasper and dissector ready)
- R pillar of the crus is dissected until lower L pillar is reached (prepare grasping forceps)
- Grasping forceps are placed on stomach and retracted laterally and caudally. (Placed through uppermost trocar)
- L pillar is localized and posterior vagus nerve is identified. Retroesophageal areas are dissected. (Have laparoscopic scissors, coagulation hook, ligating clips ready)
- L pillar is dissected cephalad (Have 2-0 silk suture on needle holder, laparoscopic scissors, coagulation hook, ligating clips ready)
- Grasping forceps are applied to the stomach and counter retraction is applied to expose gastrosplenic ligament. Vessels are isolated w coagulation hook and clipped. (make sure Maloney dilators are ready)
- Fundus is grasped and passed behind the esophagus and regrasped on the other side. Maloney dilators are introduced to prevent torsion or stricture.
- Interrupted 2-0 silk sutures are placed through stomach and anterior wall of esophagus to create gastric wrap (4-6). Mahoney dilator is removed and replaced w NG.
- Hemostasis is achieved, instruments are removed, and incision is closed. (Have dressings ready)
What are some postop considerations for a laparoscopic nissen fundoplication?
-Pt is immediately transported to PACU
-If no complications, pt returns to ADLs in 2-4 weeks
-Complications include esophageal or gastric perforation; pleural perforation; conversion to laparotomy; dysphagia; necrosis of wrap or failure of the wrap; pulmonary infection; incisional hernia; SSI; hemorrhage; failure to gain relief from preoperative complaint.
What wound classification is a laparoscopic nissen fundoplication?
Class I: Clean
What are some components of Gastric Ulcer Disease?
S&Sx: Epigastric pain radiating to back, weight loss, pain from indigested food
Dx: Bx, upper GI series, endoscopy
Tx: Diet, meds, antacids, vagotomy, ulcer excision
What are some components of Gastritis?
S&Sx: NVD, bleeding, mucosal disruption, diffuse erythema
Dx: Hx, upper GI series, endoscopy
Tx: Withdrawal of noxious agents, stomach decompression, antacids, H2 blockers
What are some components of gastric polyp?
S&Sx: asymptomatic
Dx: endoscopy
Tx: Bx, conservative tx
What are some components of Bezoar (mass of indigestible vegetable fiber)?
S&Sx: indigestion, pain
Dx: Hx, endoscopy
Tx: endoscopic/surgical removal
What are some components of carcinoma, lymphoma, leiomyoma, and leiomyosarcoma?
S&Sx: wt loss, epigastric pain, dysphagia, hematamesis, melena
Dx: lab studies, upper GI, endoscopy, Bx
Tx: Surgical resection
What is a gastrostomy?
Surgical creation of a an opening (fistula tract) from gastric mucosa to skin in order to instill nutrition or drain gastric contents. May be lined w mucosa (long term) or serosa (temporary). May be performed in conjunction w a gastrectomy. Variety of ways tract can be created including
Open- Placement of synthetic tubes (Stamm/Witzel)
-Rolling gastric tissue into tubes (Spivak-Watsuji gastrostomy)
Laparoscopic- Raising a flap of gastric tissue (Janeway gastrostomy)
Percutaneous- Utilizing a transected portion of the jejunum
How are Maloney dilators inserted?
Cannot be inserted through the sterile field. Passed down the esophagus by anesthesia.
What are the steps for a percutaneous endoscopic gastrostomy?
- Skin site exit point is one-third of the way between the midclavicular line at the rib margin and the umbilicus
- Placement site for incision is mid-stomach
- Peds gastroscope is introduced and the stomach is insufflated
- Finger is pressed on abd wall and indentation in stomach is observed through endoscope
- Local anesthetic is injected at incision site and trocar needle is passed into stomach
- Placement of needle is confirmed visually and trocar is removed
- Wire/nylon loop is passed through the needle and snared by a loop in the gastroscope
- Gastroscope is removed and snare is pulled PO where its attached to the gastrostomy tube
- Procedure is reversed pulling the tube down the esophagus into the stomach w proximal end being drawn through the stab incision and secured
What is an esophagectomy w esophagogastostomy
Tx for esophageal or stomach tumors or structures. The diseased portions of the esophagus and stomach are removed and the remaining sections are anastomosed.
What are the steps for a Stamm Gastrostomy?
- Upper midline incision is made
- Puncture wound is made on middle anterior wall of the stomach
- A Foley/Malcot/Pezzer catheter is inserted and secured w two purse string sutures
- The catheter exits the skin in the L hypochondriac region
- The stomach is secured to anterior abdominal wall
- The tube is secured to the skin
- The abdominal wound is closed
What is a partial (subtotal) gastrectomy?
In an antrectomy, the distal portion of the stomach and pylorus is removed. There are two types Billroth 1 and 2
What is Billroth I: Gastroduodenostomy
Anatomosed to the duodenum
What is Billroth II: Gastrojejunostomy
Anastomosed to the jejunum. This is preferred when the duodenum is scarred. The end of the duodenum is left closed.
What is a total gastrectomy?
Removal of the stomach. Uses an upper midline, bilateral subcostal (chevron) or thoracoabdominal incision. The stomach is mobilized, vessels of the stomach are ligated and a linear cutter is used to transect 1cm into the duodenum and across the distal esophagus freeing the stomach.
What is a Roux-en-Y esophojejunostomy?
18 inches of free jejunum is needed for tension-free loop and to precent reflex. There are two anastomoses: esophagojejunal and a jejunojejunal.
Hey cutie
What is Meckel’s diverticula?
Remnant of structures within the fetal digestive tract that were not fully reabsorbed before birth
What is volvulus?
Twisting of the intestine
What is intussusception?
