general surgery

Question 1

describe the layers of the abdomen

Answer 1

Skin
• Subcutaneous fatty layer (Camper’s fascia)
• Muscle (if cut)
• Deep membranous fascial layer (Scarpa’s)
• Linea alba.
• External oblique
• Internal oblique
• Transverse abdominis
• Transversalis fascia.
• Preperitoneal fat.
• Parietal peritoneum.

Question 2

describe the incisions primarily used to gain access to the abdominal cavity

Answer 2

• vertical incisions (median- upper midline, lower midline, full midline)
• paramedian (lower left for sigmoid surgery, upper right for access much of the kidneys, spleen, and adrenal glands)
• kocher/RT. subcostal ( for biliary tract surgery especially for cholecystectomy)
• left subcostal ( for splenectomy)
• Mcburney (appendectomy)
• lanz (appendectomy, better cosmetic scar on healing)
• pfannenstiel ( GYN procedures, pelvic surgeries
• thoracoabdominal/lateral (access for extensive esophagogastric surgery (left), emergency hepatic resection (right), nephrectomy)
• chevron/roof top ( gastroectomy, adrenalectomy, bilateral; hepatic trnasplantation/resection

Question 3

analyze the opening and closing techniques for vertical incision median

Answer 3

opening-
skin and subcutaneous tissue are incised in a line over the linea alba.
small bleeding vessels, “bleeders” are coagulated.
linea alba and extraperitoneal fat are incised to the perioneum.

closing-
closed in layers.
peritoneum is closed separately with a continuous 2-0 absorbable suture or incorapted with other layers.
fascia closed with #0 or #1 braided nonabsorbable sutures placed 1 apart.
skin is closed with 4-0 nylon, 4-0 subcutucular absorbable sutures or skin staples.

Question 4

analyze the opening and closing techniques for vertical incision-paramedian

Answer 4

opening: skin and subcutaneous tissue are incised to the anterior rectus sheath
anterior rectus is dissected away from the muscle.
rectus muscle is retracted laterally
posterior rectus sheath and peritoneum are incised in the same plane as the anterior sheath

closing:
peritoneum and posterior rectus sheath are closed as one layer, 2-0 or 0 absorbable sutures
anterior sheath closed, 0 absorbable on nonabsorbable
subcutaneous tissue may be approximated with interrupted plain gut, chromic, or similar suture (surgeon’s preference)
skin is closed as median incision

Question 5

analyze the opening and closing techniques of the oblique incision; kocher subcostal

Answer 5

opening:
incision begins at the midline 2.5-5 cm below the xiphoid and extends obliquely lateral about 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 an outward direction for a short distance and retracted to expose the peritoneum
the small eight dorsal nerve may be divided; however, the ninth dorsal nerve must be preserved to prevent subsequent weakening of the abdominal musculature
peritoneum is incised to the length of the incision

closing:
peritoneum and fascia are closed with 0 synthetic absorbable or nonabsorbable suture.
subcutaneous tissue may be approximated with 2-0 absorbable suture.
skin is closed with interrupted nylon subcuticularly, or with staples according to surgeon’s preference.

Question 6

analyze the opening and closing techniques for transverse incision

Answer 6

opening:
upper transverse- incised bilaterally as described in the subcostal incision, and joined at the midline.

closing:
peritoneum and fascia are closed with 0 absorbable or nonabsorbable suture of surgeon’s preference.
subsutaneous tissue may be approximated with a 2-0 absorbable suture according to surgeon’s preference
skin is closed with nylon suture, subcuticularly or with staples according to surgeon’s preference.

Question 7

analyze the opening and closing techniques for thoracoabdominal

Answer 7

opening:
incision begins as a standard midline or left upper paramedian incision.
extended obliquely over the thorax along the eighth costal interspace
diaphragm is divided radially toward the esophageal hiatus for as far as necessary

closing:
begins with repair of the diaphragm with #1 silk or suture of surgeon’s preference
a chest tube is placed through a stab wound in the ninth intercostal space along the posterior axillary line.
standard closure of the chest
standard median or paramedial closure.

Question 8

what incisions are used for an appendectomy?

Answer 8

• Mcburney
• Lanz for better cosmetic results

Question 9

what type of suture is used for an appendectomy?

Answer 9

• a purse string suturing technique is often used on the appendiceal stump then inverted.

Question 10

lap appendectomy can be transected with what?

Answer 10

• endoscopic linear stapler, ligating loop instrument, suturing instrument.

Question 11

common steps for colon resection

Answer 11

• moist laps once colon is freed to isolate section to be removed and protect from spillage when colon is open (towels are not placed within the surgical wound)
• bowel technique
• four intestinal clamps
• get staplers ready and reloads

Question 12

division of mesentery from the colon

Answer 12

clamp
clamp
cut
tie
cut
tie
cut

Question 13

where is the liver?

Answer 13

• located in the right upper abdominal quadrant of the abdominal cavity beneath the diaphragm and directly above the stomach
• divided into 8 segments
• highly vascular and friable organ

Question 14

whipple procedure

Answer 14

• pancreaticoduodenectomy
  -anastomosis
  proximal end of the jejunum is anastomosed to the pancreatic body
  CBD is anastomosed to the jejunum in end-to-side technique
  distal stomach is anastomosed to the jejunum end-to-side