APPENDICULAR LUMP

What are the various positions of appendix?

· Retrocaecal

· Pelvic

· Pre-ileal

· Post-ileal.

What is an appendicular lump?

In cases of acute appendicitis, the infection can spread beyond the appendix to

· Omentum

· Ileum

· Caecum

· Parietal peritoneum.

All these structures get inflamed and produce exudates; this causes adherence of these organs. These inflamed adherent organs form the appendicular mass. There may be pus in this mass.

How do you treat an appendicular lump?

The treatment is non-operative:

· Bed rest

· Nil orally (by month)

· Nutrition by intravenous feeding

· Nasogastric suction if there is distension

· Antibiotics (broad spectrum) for aerobes and anaerobes

· Frequent re-examination to assess the size of mass, fever and pulse rate

· Surgical intervention if no improvement occurs.

 

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APPENDICECTOMY PROCEDURE

APPENDICECTOMY

What are the indications of appendicectomy?

· In cases of acute or recurrent acute infection (acute or recurrent acute appendicitis) of the appendix or tumors of the appendix (carcinoid)

· Access to the organs in the right iliac fossa.

· To excise the diseased appendix.

Positions of the patient

Supine.

Anaestheia given

General, epidural or spinal.

· A right gridiron incision is given.

· Caecum is identified and a Taenia coli to the base of the appendix is traced.

· Next the appendix is mobilised to its base by dividing mesoappendix between ligratures.

· The base of appendix is crushed with haemostat and the crushed area is tied with 2/0 silk ligrature.

· A cut is given above tie and appendix is removed and sent for histopathology analysis.

· The appendicular stump is inverted with a purse-string on the caecum.

Instruments used

Appendicectomy set

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Bowel Anastomosis

When is an intestinal resection indicated?

The operation may be required in the following cases:

· In cases of strangulation and gangrene of bowel

· Volvulus

· Intussusception (irreducible)

· Tuberculosis of intestine with stricture

· Intestinal fistula

· Regional enteritis

· Ulcerative colitis

· Tumour of intestines.

What are the types of anastomosis?

· End to end

· End to side

· Side to side

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BOWEL RESECTION Procedure 6

SMALL BOWEL RESECTION

Position of the patient

Suspine

Anaesthesia

General

Surgical steps

· Open the abdomen (paramedian) and gain entry to the peritoneal cavity.

· Identify the area to be resected.

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

· The apex of the V is towards the root of the mesentery.

· Divide bowel to be removed obliquely, removing more of antimesenteric border between non-crushing clamps.

· Approximate non-crushing clamps to appose the two cut ends of bowel.

· 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 required

· Laparotomy set,1

· Allen intestinal clamps, 1 pair

When is an intestinal resection indicated?

The operation may be required in the following cases:

· In cases of strangulation and gangrene of bowel

· Volvulus

· Intussusception (irreducible)

· Tuberculosis of intestine with stricture

· Intestinal fistula

· Regional enteritis


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PROCEDURES 5 Jejunostomy

Jejunostomy

Objective

To provide a route for parenteral nutrition

Position

Supine

Anesthesia

General or local

Procedure

*locate a proximal loop of jejunum close to deudeno-jejunal flexure

 (DJ)

*Select a site 15-20 cm from DJ

*Through a stab wound on antimesenteric border introduce a carheter

 14F foley

*Close the opening around the catheter with catgut suture

*Bury the catheter in a short tunnel in the wall

*Bring out the catheter through a stab wound in the abdominal wall.

Instruments.

Gastro intestinal set

Foley 14 F

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GASTROSTOMY PROCEDURE 4

Gastrostomy

When is gastrostomy required ?

In cases of;

* Obstruction of oesophagus e.g.carcinoma to feed the patient and drain the stomach

* In cases of prolonged ileus or pacreatitis to keep stomach empty

Position of patient.

Supine.

Anaesthesia

General or local

Surgical steps

*Small midline incision

*Left anterior wall of stomach is held between two babcock's forceps midway between greater and lesser curvature

*Two purse string sutures from a selected site for entry.

*The stomach is incised at the selected point.A 14F foley's catheter is inserted through the opening and the two purse string tied around the catheter.

*The catheter is brought out through a stab on the anterior abdominal wall

*The stomach is anchored to the posterior peritoneum and rectus sheath.

Instruments used

*Laprotomy set

*Foley's catheter 14F
*Fine artery forceps 4

 

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PYLOROPLASTY PROCEDURE 3

PYLOROPLASTY

What are the indications of pyloroplasty?

·        In cases to avoid holding up to stomach contents.

·        In patients of peptic ulcer after truncal vagotomy.

·        In patients having cancer of oesophagus after total oesophagectomy to enlarge the passage of the pylorus.

Position of the patient

Suspine.

Anaesthesia given

General.

Surgical steps

·        First the pylorus is located and a longitudinal incision, 3 – 5 cm on stomach side and 2.5cm on duodenal side is given cutting through the pylorus. All bleeding is controlled with ligatures.

·        The longitudinal incision is sutured in a transverse direction using interrupted sutures.

Instruments used

General set, 1

Laparotomy set, 1

Fine artery forceps, 4

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