Procedures Flashcards
Describe the indications for cholecystectomy
- Symptomatic gallstones (biliary colic)
- Acute cholecystitis or cholangitis
- Gallstone pancreatitis (delayed)
Describe the procedure for cholecystectomy briefly with reference to key anatomy
Usually laparoscopic
- Identify Calot’s triangle (cystic duct, hepatic duct, free liver edge)- important to ensure correct ligation of cystic artery
- Dissect and ligate cystic duct + cystic artery
- Removal GB
Describe the complications of cholecystectomy
Surgical: bile leak, damage to surrounding structures (eg hepatic artery), bleeding, conversion to open
Anaesthetic: N+V, sore throat, muscle aches, allergy/anaphylaxis, death
Short term post-op: pain, wound infection, DVT
Long term post-op: adhesions, recurrence of gallstones, steatorrhoea
Describe the indications for gastrectomy
- Gastric malignancy
- Bariatric surgery
- Peptic ulcer
Describe the complications of gastrectomy
Surgical: damage to surrounding structures
Anaesthetic
Immediate post-op: bleeding, wound infection, pain, anastomotic leak
Long-term post-op: dumping syndrome, diarrhoea, vitamin deficiency, small stomach syndrome, adhesions
Describe the post-op care for gastrectomy
Immediate:
- NBM, IV fluids/TPN for 1-2 weeks
- NGT + suction
Long-term:
- Vitamin supplementation (B12, iron)
- Small frequent meals, low dairy
What are the types of gastrectomy?
- Partial
- Total
- Sleeve (remove left side)
- Oesophagogastrectomy
Describe the indications for Nissen fundoplication
In following conditions when severe/not responding to medical Mx: -Severe GORD -Barrett's oesophagus -Hiatus hernia To reduce acid moving up the oesophagus
Describe the procedure of fundoplication
Laparoscopic
- Narrow the oesophageal hiatus
- Wrap the fundus of the stomach around the lower oesophagus
Describe the complications of fundoplication
Surgical: damage to surrounding structures
Anaesthetic: see elsewhere
Short term post-op: pain, bleeding, infection, DVT
Long-term post-op: dysphagia, failure to control symptoms, adhesions
Describe the post-op care of fundoplication
- May go home same/next day
- Soft food diet for first 1-2 weeks
Describe the indications for oesophagectomy
-Oesophageal malignancy
Describe the types of oesophagectomy
- Ivor Lewis: abdo incision + right thoracotomy. Middle third tumours
- Minimally invasive: w laparoscopy + thoracoscopy
- Transhiatal: only neck and abdo incision
- McKeown: upper third tumour. Three incision.
Describe the procedure of oesophagectomy briefly
Resect the tumour area
Mobilise stomach into chest
Anastomose the distal oesophagus to stomach
Describe the post-op care for oesophagectomy
Diet: clear liquid -> liquid -> soft food -> normal diet
Jejunostomy tube until eating normally eg. 4-6 weeks
Describe the complications of oesophagectomy
Surgical: bleeding, recurrent laryngeal nerve damage
Anaesthetic
Short term post-op: pain, wound infection, DVT, anastomotic leak
Long term post-op: dumping syndrome, weight loss, GORD, dysphagia, recurrence, adhesions
Describe the indications for splenectomy
- Splenomegaly
- Ruptured spleen
- Haematological malignancy
- Abscess
Describe the complications of splenectomy
Intra-operative: bleeding, damage to surrounding structures
Anaesthetic
Short term post-op: pain, wound infection/dehiscence, DVT
Long term post-op: adhesions, infections (encapsulated bacteria)
Describe the indications for Whipple’s procedure
Pancreatic lesions: cancer, cysts
Cholangiocarcinoma
Describe the process of a Whipple’s procedure (briefly)
Open surgery (Chevron, midline)
- Dissect + move pancreas
- Remove the antrum to duodenum + head of pancreas + GB
- Anastomose stomach and jejunum
- Attach pancreas to free end of jejunum
Describe the complications of a Whipple’s procedure
Intra-operative: bleeding, damage to surrounding structures
Anaesthetic
Short term post-op: wound infection, bile leak, DVT, pancreatitis
Long term post-op: DM, recurrence, delayed gastric emptying
Describe the complications of rectal prolapse repair
Intra-operative: bleeding, damage to surrounding structures
Anaesthetic
Short term post-op: wound infection, DVT, pain, bowel obstruction
Long term post-op: recurrence, fistula, sexual dysfunction, mesh complications
Describe the process of rectal prolapse repair
Can be open/lap abdominal approach (rectopexy) or perineal
Abdo: use sutures/mesh sling to attach rectum to sacrum
Delorme: shorten rectum by removing mucosa
Altemeier: resect rectum segment + anastomose to sigmoid colon
Describe the pros and cons of open vs laparoscopic abdominal surgery
Open:
- Pros: better exposure, allows full resection/removal of large structures
- Cons: longer recovery time, higher rate of complications (wound infection, pain, bleeding)
Laparoscopic:
- Pros: smaller scars, decreased risk of complications, shorter recovery
- Cons: may not be practical (eg. inserting large stents), reduced visibility, not used in emergencies
Describe the indications for laparotomy
Perforation
Intraperitoneal bleeding
Penetrating trauma
Malignancy (resection)
Describe the procedure for laparoscopy
- Make 3-4 0.5mm incisions for entry, usually 1 umbilical
- Tilt table, inflate abdo w carbon dioxide gas
- Insert trocars + instruments
Describe the post-op side effects of laparoscopic surgery + post-op care
- Bloating
- Nausea
- Pain in chest/shoulders/neck
May go home same day depending on complications
Return to work after 1 week ish
Describe the indications for liver transplant
Acute liver failure eg paracetamol OD, hepatitis
Cirrhosis
Malignancy
Describe the complications of liver transplant
Intra-operative: bleeding, bile leak, damage to surrounding structures
Anaesthetic
Short term post-op: delayed graft function, pain, wound infection, anastomotic leak, DVT
Long term post-op: recurrence, graft rejection, comp of immunosuppression
Describe the relevant liver anatomy + types of resection
Liver divided into 2 lobes + 8 segments
Each has own portal triad (hepatic A and V, portal V)
Anatomic resection: resection of lobes/segments
Non-anatomic resection: resection of lesion w/o regard to lobes/segments
Describe the indications for haemorrhoidectomy
Grade 3-4
Failure of medical management
Incarcerated haemorrhoids
What are the types of haemorroidectomy
Closed: excision + closure
Open: no closure of wound
Stapling + rubber band ligation
Describe the complications of haemorrhoidectomy
Intra-operative: damage to surrounding structures, bleeding
Anaesthetic
Short term post-op: pain, bleeding, wound infection, urinary retention
Long term post-op: recurrence, incontinence, stricture
Describe the types of bariatric surgery
Most common:
- Roux-en-Y gastric bypass: resect stomach + connect gastric pouch to jejunum, leave stomach + duodenum in situ
- Sleeve gastrectomy: remove left side of stomach-> smaller tube-like stomach, holds less food
Others:
-Gastric banding
Describe the indications for bariatric surgery
- Obesity (class III- BMI >40)
- Obesity (class II- BMI 35-39.9) + complications eg. OA, T2DM
Describe the benefits of bariatric surgery
- Considerable weight loss (usually in first 1-2 years)
- Reduction in mortality due to obesity
- Reduction in T2DM + other complications
Describe the pre-op considerations for bariatric surgery
- Suitability + anaesthetic review
- OGD
- Liver reduction diet for 3 weeks prior to surgery (strict calorie reduction to shrink liver)
Describe the post-op care for bariatric surgery
- Admission usually for 1 night
- Diet: liquid 2 wk -> pureed 2 wk -> soft food
- Thrombotic prophylaxis
- Stop/change diabetes medication
- Follow up with bariatric dietician
- Supplementation (B12 for life)
Describe the complications of bariatric surgery
- Intra-operative: bleeding, damage to surrounding structures,
- Anaesthetic: may be significant eg. difficulty intubating, cardiac complications, death
- Short term post-op: DVT, pain, wound infection, pneumonia, anastomotic leak
- Long term post-op: weight regain, change in bowel habits, dumping syndrome, strictures, adhesions, nutritional deficiency
