Thoracic surgery Mediastinoscopy

Mediastinoscopy

Objective

In cases of suspected malignancy:

•   Endoscopic visualization of the mediastinum (tracheobron­cheal junction, bronchi, aortic arch and regional lymph nodes) 

•   Biopsy if required.

Position

Supine.

Anesthesia

General.

Procedure

1.  Transverse incision over the suprasternal notch and extended down to the pretracheal fascia. 

2.  Blunt dissection the superior mediastinum is entered.

3.  Scope is passed.

4.  Avoid injury to nearby blood vessels.

5.  Lymph node tissue biopsied.

6.  Hemostasis is achieved.

7.  Scope is removed.

8.  Wound is closed.

Instrument

•   Mediastinoscope (Fig. 19.11)

•   Electrosurgical unit 

•   Suction

•   Fiberoptic light source 

•   Basin set 

•   Blade (1) No. 15 

•   Telfa dressing pads and 22 gauge needle

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Thoracic surgery bronchoscopy

THORACIC OPERATION

Bronchoscopy

Objective

In cases of suspected bronchial lesions:

•   Endoscopy

•   For visualization of the trachea, main bronchi and their openings and the segmental bronchi 

•   Obtaining material for histopathologic and bacteriologic examination if required 

•   Foreign body removal.

Position

Supine.

Anesthesia

General.

Procedure

1.  The head is lowered.

2.  Well-lubricated scope is inserted into the mouth.

3.  The epiglottis is elevated with the tip of the bronchoscope and the scope is passed into the trachea.

4.  The scope is advanced into the bronchi.

5.  Bronchial washings, biopsy, may be obtained.

6.  The bronchial passages are well suctioned, and the scope is removed slowly.

Instruments

Rigid bronchoscopy

•   Rigid fiberoptic bronchoscope (Fig 19.8)

•   Endotracheal adaptor 

•   Fiberoptic telescope 

•   Fiberoptic light cords (2) 

•   Suction cannula (Fig. 19.9) 

•   Suction tubing 

•   Specimen collectors 

•   Biopsy forceps 

•   Sponge carriers (2) (Fig. 19.10)

•   Grasping forceps 

•   Lubricant

•   Bronchoscopy sponges 

•   Small basin with sterile saline and syringe 

•   Telfa dressing pads and 25 gauge needle 

•   Laser may be employed.

Flexible bronchoscopy

•   Flexible fiberoptic bronchoscope 

•   Endotracheal adaptor 

•   Fiberoptic light cord 

•   Biopsy forceps 

•   Brush

•   Culture jar for biopsy specimen 

•   Small basin with sterile saline and syringe 

•   Suction tubing 

•   Specimen collector 

•   Lubricant

•   Telfa dressing pads and 25 gauge needle.

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Plastic Surgery Reimplantation hand fingers

Replantation-Hand or Fingers

Objective

Replantation of amputated parts—hand or fingers—by micro­surgery.

Position

Supine with arm resting on a hand table.

Anesthesia

General + brachial.

Procedure

1.  Prepare amputated part and the stump and dissect its vessels, nerves, tendons and bone.

2.  Fixation of the amputated part with K wires.

3.  Repair tendons.

4.  Anastomosis of arteries, veins and nerves.

5.  Hemostasis.

6.  Closure dressing and splinting.

Instruments

•   Plastic surgery set

•   Microsurgery set

•   Hand surgery set consisting of:

     a.  Tourniquet (pneumatic)

     b.  Hand table

     c.  Rubber bands

     d.  K wires of different sizes

     e.  Wire driver with Jacob chuck and key

     f.   Fine periosteum elevation

     g.  Bone cutter

     h.  Wire cutting pliers

     i.   Esmarch’s bandage.

Sutures

•   Prolene 6 ‘0’ on curved round body needle (for tagging of vessels)

•   Prolene 4 ‘0’ on curved round body needle (for tendon repair)

•   Nylon 10 ‘0’ on 4 mm curved round body needle

•   Nylon 11 ‘0’ on 3.75 mm curved round body needle (for distal finger amputations)

•   Nylon 9 ‘0’ on 6 mm curved round body needle (for proximal and hand amputations)

•   Nylon 5 ‘0’ on curved cutting needle for skin

•   Dressing paraffin gauze

•   Gamjee pads

•   Velroc or Gypsona for splinting.

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Plastic Surgery microsurgical free graft

Microsurgical Free Flap Transfers

Objectives

•   Reconstruction of defects 

•   By transfer of a flap from a distant area wherein the artery and vein supplying the flap is anastomosed to an artery and vein in the recipient area 

•   Under magnification with an operating microscope

•   Operation may be done by two teams simultaneously.

Position

Depending upon the site of recipient and donor areas.

Anesthesia

General.

Procedure

1.  Clean and drape recipient and donor areas.

2.  Prepare recipient area.

3.  Dissect and prepare recipient artery and vein.

4.  Plan and flap.

5.  Raise and prepare the flap and dissect its artery and veins.

6.  Divide flap vessels, transfer flap to the recipient area.

7.  Anastomose the vessels/Close recipient area by direct closure or skin grafting.

Instruments

•   Plastic surgery set 

•   Skin grafting set 

•   Microsurgery set consisting of: 

     a.  Jewellers forceps No. 2                   2   

     b.  Jewellers forceps No. 5                   2

     c.  Vessel dilator                                  1 

     d.  Curved blunt tipped dissecting    1
microscissors 

     e.  Straight sharp microscissors          1

     f.   Microneedle holder straight          1
or curved 

     g.  Microvessel clamps                         4 

     h.  Microvessel approximator clamps   2 

     i.   Visibility background                     1

     j.   Fine suction tip                              1

     k.  Irrigation syringe with                    1
22 G venflon 

     l.   Operating microscope                    1

     m. Sterile knobs for microscope (set) 1

     n.  Microsurgical cellulose swabs

     o.  Heparin saline solution (N saline 50 mls + heparin 5000 units + xylocaine 2% 5 mls). 

Sutures

•   As for general plastic surgery 

•   10 ‘0’ Nylon on 6 mm curved round body needle or 9 ‘0’ nylon on 6 mm curved round body needle.

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Plastic Surgery Full thickness skin graft

Full Thickness Skin Graft (Wolfe Graft)

Objective

Coverage of small skin defects on face, hand and fingers following surgical excision of benign lesions or traumatic skin loss. 

Position

Depends upon site.

Anesthesia

Local or general.

Procedure

   1.  Clean and drape donor and recipient areas.

   2.  Mark and excise the lesion.

   3.  Secure hemostasis.

   4.  Make a template of the defect.

   5.  Transfer template to donor area. 

   6.  Mark and harvest graft.

   7.  Close donor area.

   8.  Thin out graft to remove fat from undersurface.

   9.  Suture graft in recipient bed.

10.  Apply tie-over dressing. 

Instruments

•   Plastic surgery set 

•   Sterile polyvinyl sheet for patter outline template

•   Vaseline/paraffin impregnated nonadherent gauze (Jelonet, Fairly) 

•   Irrigation syringe 

•   Cotton soaked in betadine or acriflavin solution.

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Plasti surgery split thcnkess graft

Split Skin (Thiersch) Grafting)

Objective

To cover wounds with loss of skin which cannot be closed by approximation of skin edges.

Position

Variable according to the site of wound.

Anesthesia

GA (LA can be used for small wounds).

Procedures

1.  Clean and drape donor and recipient areas.

2.  Take skin graft.

3.  Prepare recipient bed by scraping/excision.

4.  Secure hemostasis.

5.  Apply nonadherent gauze.

6.  Dressing.

7.  Tie over dressing over trunk. Circumferential pressure dressing over limbs.

8.  Splint the limb with Velroc/Gypsona POP slab.

Instruments

Skin grafting set consisting of:

•   Skin grafting knife (Humby, Blair or Electric dermatome)

•   Appropriate blade of skin grafting knife

•   Skin graft boards (wooden or stainless steel)

•   Skin graft mesher (optional)

•   Liquid paraffin (sterile)

•   Vaseline/paraffin impregnated gauze (Fairly, Jelonet)

•   Sterile cotton soaked in betadine or acriflavin

•   Gamjee pads and crepe bandages

•   Adrenalin in saline (1 in 100,000)

•   Syringe for irrigation

•   Velroc or Gypsona for splinting

•   Sutures 3 ‘0’ Nylon/silk on cutting needle.

•           4 ‘0’ chromic catgut on curved cutting needle for children

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Plastic surgery Z plasty

Scar Excision/Revision and Z Plasty

Objective

Patients with ugly scars

•   Require with or without Z plasty 

•   To achieve a fine inconspicuous scar.

Position

Supine or prone to provide access to scar.

Anesthesia

Local.

Procedure

1.  Plan and mark incisions.

2.  Excise scar.

3.  Z plasty incisions if required.

4.  Undermine and advance margins.

5.  Hemostasis.

6.  Closure in layers.

Instruments + Sutures

Limited plastic procedure set.

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Plastic Surgery Liposuction

Liposuction

Objective

In case of excessive fat on thighs and abdomen:

•   Removal of subcutaneous fat deposits employing a high pressure vacuum suctioning device.

Position

Supine.

Anesthesia

General.

Procedure

1.  Surgeon may preinject the areas where liposuction is to be employed with a solution of local anesthesia with epineph­rine, to reduce bleeding and hyaluronidase (Wydase).

2.  To minimize tissue swelling.

3.  Through a 1 cm incision a blunt suction tip is inserted and used to tunnel under the skin.

4.  The excess subcutaneous fat is then suctioned from the pretunneled areas using a high pressure vacuum.

5.  The incisions are closed.

6.  Compression dressing is applied.

Instruments

•   Minor procedure set 

•   Blunt suction tips or blunt cannulas 

•   High pressure vacuum unit 

•   Basin set 

•   Blades (1) No. 15 

•   Marking pen 

•   Sterile, plastic adhesive drape tube 

•   Suction tubing 

•   Syringes (2) 30 ml 

•   Needles (2) 22 gauge

•   Intravenous antibiotic 

•   Local anesthetic with epinephrine 

•   Hyaluronidase (Wydase) 

•   Pressure girdle.

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Plastic surgery Palmer Fasciectomy

Palmar Fasciectomy

Objective

In cases of contracture (Depuytren’s):

•   Excision of the fascia of the palm to correct the deformity.

Position

Supine hand on hand rest.

Anesthesia

General or regional.

Procedure

1.  Short longitudinal palmar incision is next to the contraction band which is resected.

2.  For more extensive disease a longer incision with a Z plasty arrangement.

3.  Care is taken to avoid injury to digital nerves and flexor tendons.

4.  Wound closure may be done by primary suture.

5.  An anterior splint is applied.

Instruments

•   Limited plastic procedure set 

•   Basin set 

•   Tube stockinette 

•   Esmarch bandage 

•   Blades (2) No. 15 

•   Marking pen.

Any questions be sent to drmmkapur@gmail.com

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