Ileo-colostomy

Ileocolostomy

Indications

In cases of:

•   In poor risk patients with obstruction due to ileocecal tuberculosis

•   Unresectable growth of transverse of descending colon

•   Ileotransverse Colostomy to bypass the obstruction because of unresectable cancer of cecum or ascending colon.

Position

Supine.

Anesthesia

General.

Procedure

1.  An upper or lower paramedian or midline incision.

2.  Take a mobile loop of terminal ileum and bring it in apposition to transverse or sigmoid colon as the case may be.

3.  Incise ileum and colon between clamps.

4.  Carry out a two layer anastomosis using continuous or interrupted sutures making a 4 cm stoma.

Instruments

•   General set, 1

•   Gastrointestinal set, 1

•   Dennis anastomosis clamp (Fig. 9.21).

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Small Bowel Resection

8.  Small Bowel Resection and Entero-Enterostomy

Objective

In case of small bowel obstruction due to:

•   Inflammation

•   Tumor.

     Bypass the obstruction or remove the deceased segment and restore continuity of the bowel.

Position

Supine.

Anesthesia

General.

Procedure

1.  Open the abdomen gain entry to the peritoneal cavity.

2.  Identify area to be resected.

3.  Divide mesentery to this area in the line of a shallow V, serially between ligatures.

4.  The apex of the V is toward the root of the mesentery.

5.  Divide bowel to be removed obliquely, removing more of antimesenteric border between noncrushing clamps.

6.  Approximate noncrushing clamps to appose the two cut ends of bowel.

7.  Carry out end to end anastomosis—an inner continuous layer of catgut and an outer continuous layer of silk.

     Approximate cut end of mesentery with interrupted sutures.

Instruments

•   General set, 1

•   Gastrointestinal set, 1.

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SURGICAL PROCEDURE 8 Appendectomy

     Appendectomy

Objective

•   In cases of acute or recurrent acute infection of the appendix or tumors of the appendix or carcinoid

•   Access to the organs in the right Iliac fossa

•   To excise the deceased appendix.

Position

Supine.

Anesthesia

General, epidural or spinal.

Procedure

1.  A right gridiron incision.

2.  Deliver cecum and trace a laenia to the base of the appendix.

3.  Mobilize appendix to its base by dividing mesoappendix serially between ligatures.

4.  Crush base of appendix with hemostat and tie crushed area with 20 silk suture.

5.  Cut above tie and remove appendix (send for histology).

6.  Invert appendix stump with a purse string suture on the cecum.

Instruments

•   Appendectomy set.

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Surgical PROCEDURE 7 GASTRIC RESECTION

Gastric Resection

Objective

To remove the stomach (Partial or Total) in case of:

•   Gastric ulcer; elective or emergency

•   Trauma

•   As part of other operations, e.g. pancreaticoduodesectomy.

Position

Supine - Midline incision.

Anesthesia

General.

Principles

a.  For ulcer disease 60-70% of the stomach is resected. The left gastric artery is ligated on the stomach. Omentum is not resected.

b.  For distal gastric cancers, the left gastric artery is ligated at its origin but short gastric arteries are preserved and 80% of stomach is resected.

c.  For gastric cancers involving the body or cardia, the entire stomach is resected with or the entire omentum. The left gastric artery is ligated at its origin and all short gastric arteries are ligated. The spleen may be removed in continuity to increase the radicality of the operation but is controversial. In b and c all draining lymph nodes are removed.

Procedure

1.  The stomach is mobilized after ligating the right gastric and gastroepiploic vessels at their origin.

2.  The duodenum is mobilized off the pancreas and divided.

3.  The distal end of the duodenum is closed in layers or stapled.

4.  The stomach is turned back to identify the left gastric artery is divided between ligatures.

5.  The stomach is resected and a gastrojejunostomy is fashioned.

6.  If a total gastrectomy is performed, then an esophago-jejunal “roux-en-y” anastomosis is done.

7.  The wound is closed in layers after draining the area of the duodenal stump.

Instruments

•   General set, 1

•   Gastrointestinal set, 1.

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SURGICAL PROCEDURE 5 Jejunostomy

5.  Jejunostomy

Objective

To provide a route for enteral nutrition.

Position

Supine.

Anesthesia

General or Local.

Procedure

•   Locate a proximal loop of jejunum at the duodenojejunal flexure (D-J)

•   Select a site 15-20 cm from D-J flexure

•   Through a stab incision on the antimesenteric border, put in a catheter

•   Close the incision around stab using catgut sutures

•   Create a valve by burying the tube in a short tunnel in the jejunal wall. Take care not to narrow jejunal lumen

•   Bring out tube through a stab in anterior abdominal wall.

Instruments

•   Gastrointestinal set, 1

•   Catheter, 14 F.

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