PROCEDURE Cholecystostomy

CHOLECYSTOSTOMY

When is this operation required`?

Cholecystostomy is required in cases of inflammation of gall bladder:

·        To open the gall bladder

·        To remove stones from the gall bladder and drain it .

Position of the patient

Supine.

Anesthesia

General.

Surgical steps

·        A vertical or right sub costal incision is given.

·        The gall bladder is surrounded with packs.

·        The bile is aspirated.

·        Now the gall bladder is incised near the fundus; the bile is aspirated and all stones are removed.

·        Do not miss stone impacted in the cystic duct.

·        Insert a 24F Foley catheter and close the opening around the cath­eter using a purse-string        suture.

·        The gall bladder is fixed to the parietal peritoneum.

·        The sub hepatic area is washed and abdomen is closed with subhe­patic suction drainage.

Instruments used

·        Laparotomy set

·        Gallstone-holding forceps

·        Foley catheter

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PROCEDURE CHOLECYSTECTOMY

CHOLECYSTECTOMY

When is this operations required?

Cholecystectomy is required in cases of

· Symptomatic gallstones

· Traumatic or inflammatory perforation of gall bladder so as to remove gall bladder.

Position of the patient

Supine.

Anaesthesia

General.

Surgical steps

· A subcostal (right) or midline incison is given.

· The gall bladder is identified and the adhesions are divided.

· Forceps is applied to fundus and to infundibulum of gall bladder and these structures are drawn to right and forward.

· The cystic artery is divided between ligatures.

· Cystic duct is divided and between ligatures after identifying junction with common bile ducts (CBD).

· The gall bladder is divided and cut open to rule out malignancy and sent for histopathology studies.

· The abdomen is closed with suction drain is subhepatic pouch.

Instruments required

· Laparotomy set

· Gallstone probe (DesJardin)

· Gallstone forceps (DesJardin)

· Ochsner’s gall bladder trocar

· CBD dilators, Bake’s

· Kerr ‘T’ tube.

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PROCEDURE ILEOCOLOSTOMY

ILEOCOLOSTOMY

When do you need this operation?

This operation may be required in the following cases:

· Poor-risk patients with obstruction due to ileocaecal tuberculosis

· Unresectable growth of transverse or descending colon.

· Transverse ileocolostomy to bypass the obstruction because of unresectable cancer of caecum or ascending colon.

Position of the patient

Supine.

Anaesthesia

General.

Surgical steps

· An upper or lower paramedian or midline incision is given.

· A mobile loop of terminal ileum is brought into apposition to transverse or sigmoid colon as the case may be.

· The ileum and colon are incised between clamps.

· Now a two-layer anastomosis is carried out using continuous or interrupted sutures making a 4-cm stoma.

· The abdomen is closed in layers.

Instruments used

· General set, 1

· Laparotomy set, 1

· Dennis anastomosis clamps, 1 pair

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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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