Augmentation Mammooplasty

Augmentation Mammoplasty

Objective

Increase of breast size by using implants in patients with small breasts.

Position

•   Supine

•   Arms abducted.

Anesthesia

General.

Procedure

1.  Submammary skin crease incision.

2.  Create a pocket by blunt and sharp dissection.

3.  Hemostasis.

4.  Insert implant.

5.  Suction drain (optional).

6.  Close in layers.

Instruments

•   General plastic procedure set 

•   Long Metzenbaum scissors curved on flat (Fig. 8.35)

•   Retractors

•   Deaver 2 (Fig. 8.94) 

•   Long forceps-nontoothed 

•   Suction drains 

•   Mammoplasty prosthesis 

•   Elastoplast for dressing 

•   Sutures:

     a.  4 ‘0’ Monocryl or chromic catgut on curved cutting needle

     b.  5 ‘0’ Prolene on curved cutting needle.

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Cleft Palate repair

Cleft Palate Repair

Objective

In cases of cleft palate:

•   Repair of congenital defects in the palate.

Position

Supine with head extended with a pillow under the shoulders and ring under the head.

Anesthesia

General with a flexometallic or oxford endotracheal tube secured on the middle of the lower lip.

Procedure

   1.  Place mouthgag.

   2.  General anesthesia through an endotracheal tube.

   3.  A local anesthetic containing epinephrine is infiltrated to aid hemostasis.

   4.  Defect, soft palate margins are incised.

   5.  Layers for oral mucosa, muscle, and nasal mucosa are developed.

   6.  The pterygoid hamulus is fractured.

   7.  Mucoperiosteal flaps are elevated.

   8.  Nasal mucosal flaps are freed and sutured.

   9.  The nasal mucosa of the soft palate is sutured.

10.  Holes may be drilled in the hard palate for suture placement.

11.  Bone grafts may be employed.

12.  Muscle layers, and the oral mucosa are sutured.

Instruments

•   Plastic limited procedure set 

•   Mouthgag-Dingman or Dott (Fig. 18.19) 

•   Long knife handle with No. 12, and No. 15 and No. 11 blade (BP)

•   Freer periosteum elevator (Fig. 14.33)

•   Curved elevators angled right and left

•   Barsky pharyngeal flap elevator (Fig. 18.20)

•   Osteotome 3 mm

•   Mallet

•   Long fine dissecting forceps toothed (Gilles, McIndoe) (Fig. 8.49)

•   Suction tubing with fine suction tip 

•   Sterile gauze cut into halves and quarters.

Sutures

•   4 ‘0’ Vicryl or catgut on curved cutting 5/8 circle needle 

•   4/0 Silk on curved cutting needle for stay sutures.

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Plastic surgery 1 cleft lip

PLASTIC SURGERY

Cleft Lip

Objective

In cases of harelip:

•   Repair of a congenital deformity of the lips.

Position

Supine with head extended by a pillow under the shoulders and a ring under the head.

Anesthesia

General, use flexometallic or oxford type endotracheal tube secured in the middle of the lower lip.

Procedure

   1.  A local anesthetic containing epinephrine is infiltrated to aid in hemostasis.

   2.  Any of several flaps are isolated and advanced.

   3.  Proper restoration the philtrum and shape of the bow of the lip is required.

   4.  Secondary repairs are performed according to individual situations even months or years later.

   5.  Palatal and alveolar deformities are repaired in due time to commensurate with the patient’s feeding requirements and tissue growth.

   6.  The incision is protected with antibiotic ointment.

   7.  The cheeks are splinted with a Logan’s bow (to counter the effects of crying).

   8.  Mark landmarks and incisions.

   9.  Incise and develop flaps.

10.  Secure hemostasis.

11.  Close in layers.

Instruments

•   Plastic surgery set 

•   Scalpel handle with No. 11 blade (BP).

Sutures

•   6 ‘0’ Prolene on curved cutting needle 

•   5 ‘0’ Monocryl on curved cutting needle 

•   5 ‘0’ Catgut on curved cutting needle 

•   5 ‘0’ Vicryl on round body needle.

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NeuroSurgical procedure 8 laminectomy

Laminectomy

Objective

In cases of spinal cord pressure (including prolapsed disc) 

•   The removal of one or more vertebral laminae 

•   To decompress the pressure.

Position

•   Cervical sitting 

•   Lumbar throracic prone (or knee elbow).

Anesthesia

General.

Procedure

   1.  A midline incision used.

   2.  The wound is deepened.

   3.  Self-retaining retractors are placed, and fascia is incised.

   4.  The paraspinous muscles and periosteum are reflected.

   5.  Sponges are packed along the vertebrae.

   6.  A larger retractor is placed from exposure.

   7.  Small portions of the laminae overlying the herniated disc are removed with a Kerrison rongeur.

   8.  Small portions of the laminae overlying the herniated disc are removed to provide adequate exposure.

   9.  Nerve roots are retracted exposing the herniated disc.

10.  The wound is irrigated.

11.  The area is examined to ensure that all protruding disc has been removed.

12.  The wound is closed in layers.

Instruments

•   Laminectomy set

•   Kerrison rongeurs and pituitary forceps tray 

•   Power drill, drill bits, cord 

•   Basin set 

•   Blades (3 or 4) No. 10, (1) No. 15 

•   Sterile, plastic adhesive drape 

•   Suction tubing 

•   Asepto or bulb syringes (2) 

•   Cottonoids

•   Gell foam and thrombin 

•   Roller gauze 2" 

•   Bone wax 

•   Antibiotic irrigation.

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NEURO SURGICAL procedeur 7 Peripheral nerve repair

Peripheral Nerve Repair

Objective

The repair of a severed peripheral nerve to achieve: 

•   Accurate apposition by elimination rotational malposition 

•   Excision of neuroma 

•   Accurate suturing of nerve sheath.

Position

Varies with nerve for repair.

Anesthesia

Local, spinal or general.

Procedure

1.  Skin incision for direct access to severed nerve site.

2.  Muscles split or retracted.

3.  Nerve mobilized to relieve tension.

4.  A large gap in nerve ends may require nerve graft.

5.  Fibrous neuroma excised.

6.  Nerve sheath sutured using non-absorbable suture.

7.  Wrap repaired nerve in silastic sheet cover.

8.  Wound closed.

Instruments

•   General set 

•   Fine dissecting forceps, toothed (Gillies), 2 

•   Fine dissecting forceps, non-toothed (McIndoe), 2 

•   Micro dissecting forceps 

•   Micro artery forceps 

•   Fine artery forceps, curved on flat (Mosquito), 6 

•   Fine artery forceps, sharp points Iris scissors, curved on flat, sharp points 

•   Razor blades breaker and holder 

•   Razor blades 

•   Plastic tubing or tape for nerve traction 

•   Retractor, self-retaining (Mayo) 

•   Plaster of Paris back slab, or similar splint 

•   Nerve sutures for both operation areas 1 or 0.75 (5/0 or 6/0) synthetic non-absorbable on a small curved round-bodied non-traumatic needle 

•   19 Micron metallized synthetic non-absorbable suture 

•   Ligatures and sutures for an arm operation 

•   2 and 2.5 (3/0 and 2/0) plain catgut or synthetic absorbable for ligatures 

•   3(0) Chromic catgut or synthetic absorbable on a medium half-circle cutting needle for skin sutures 

•   2.5 (2/0) synthetic non-absorbable or silk on a medium curved cutting needle for skin sutures 

•   Ligatures and sutures for a leg operation 

•   2.5 and 3 (2/0 and 0) Plain catgut or synthetic absorbable for ligatures 

•   4 or 5 (1 or 2) chromic catgut or synthetic absorbable on a medium or large half-circle cutting needle for muscle sutures.

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NEURO SURGICAL Procedure Ventrico peritoneal shunt

Ventricular Peritoneal Shunts

Objective

In cases of hydrocephalus:

•   The insertion of a valve system to relieve tension of cere­brospinal fluid from the ventricular system.

Position

Supine, patient head is slightly elevated and turned to the left.

Anesthesia

Local.

Procedure

   1.  Lines are marked for a right-sided shunt incision.

   2.  The scalp is incised.

   3.  The burr hole site in the periosteum is electrocoagulated.

   4.  The periosteum is incised.

   5.  Burr hole is made.

   6.  The dura is electrocoagulated and the outer layer incised.

   7.  Straight ventricular catheter is passed.

   8.  A premeasured length of catheter is advanced anterior to the foramen of Munro.

   9.  The transverse abdominal incision is carried down to the anterior rectus sheath.

10.  A distal catheter is passed from the scalp incision to the abdominal incision subcutaneously.

11.  The reservoir is attached to the proximal end.

12.  A longitudinal incision is made in the anterior rectus sheath.

13.  The peritoneum is grasped and incised (1 mm).

14.  The peritoneal catheter, passed intraperitoneally, is attached to the reservoir.

15.  Wounds may be irrigated with antibiotic solution.

16.  The abdominal wound is closed.

17.  The scalp incision is closed.

Instruments

•   Craniotomy set 

•   Power drill, cord 

•   Small bull dog clamp 

•   Uterine packing forceps or a long passing instrument 

•   Basin set 

•   Blades (2) No. 15 

•   Sterile, plastic adhesive drape 

•   Suction tubing 

•   Plastic syringe (3 ml) and blunt needle (18 gauge) to pump through shunt reservoir and tubing 

•   Shunt

•   Bulb syringe 

•   Graduate

•   Cottonoids

•   Gell foam and thrombin 

•   Antibiotic irrigation.

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NEURO SURGICAL Procedure 5 stereotactic surgery

Stereotactic Surgery

Objective

Accurate localization of white matter deep in brain, i.e. basal ganglia or brain stem for ablation using:

•   Electrocoagulation

•   Cryoprobe.

     The localization requires a stereotactic frame and contrast radiography.

Position

Sitting or prone.

Anesthesia

Local.

Procedure

1.  X-ray outline ventricle by injecting contrast.

2.  Stereotactic frame applied.

3.  Refer stereotactic atlas.

4.  Insert probe to required position.

5.  Lesion created in small increments.

6.  Stop when desired effect produced.

Instruments

•   As for Ventriculography

•   Micro hand drill, twist drills and drill guard 

•   Lead shot 

•   Cryoprobe or electrocoagulation unit 

•   Stereotactic frame (Leksell, Cooper, Guiot Gillingham, etc)

.Any questions be sent to drmmkapur@gmail.com

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