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Surgery - Stomas
Indications for Stomas
an incision made in surgery that connects the bladder or intestine to a bodily surface. Ileostomy, colostomy, and urostomy are the most common types of stomas; oesophagostomy, gastrostomy, jejunostomy, and caecostomy are among the others. End or loop stomas, either permanent or temporary. Malignancy in inflammatory bowel disease is optional. After a panproctocolectomy for familial polyposis or ulcerative colitis, stop ileostomies. following abdominoperineal excision for low rectal carcinomas, permanent colostomies. Loop stomas are used to temporarily divert bowel contents from sick sections of the intestines in order to safeguard distal surgery, such as an ileoanal pouch or low colorectal anastomosis, or to restore the anal sphincter.
Emergency: Ischemic bowel illness, inflammatory bowel damage, perforation, blockage, and toxic megacolon. During a Hartmann procedure, the distal end of the divided bowel is sealed or made into a mucous fistula, and the diseased distal colon is removed with the creation of an end colostomy.
Anatomy
End stoma: To create the stoma, the colon is divided and its proximal end is brought through the abdominal wall. The distal end can form a double barrel stoma in the same opening, be closed and left in the belly, or be brought out through a different incision called a mucous fistula.
Loop stomas: A stoma with two lumens is created by raising a bowel loop to the surface, opening it, then folding it back on itself. may be simpler to shut. A certain amount of "spillover" of the nearest contents.
Ileostomies: Located in the right iliac fossa, albeit not necessarily. They are designed with a spout that protrudes 2.5 cm above the skin's surface because the discharge is irritating. Liquid output occurs at a rate of 1-2 L per day, however it may decrease after a few weeks.
Colostomies: The stoma is flush with the skin and is typically located in the LIF, though it can be anywhere. Depending on the diet, the output is sporadic and has a more solid consistency (although transverse colostomies can produce semi-liquid, which can be more challenging to control).
Appliances for stomas: Comprised of a flange, which covers and shields the skin surrounding the stoma, and a pouch. There could be one or two pieces in the flange; when the pouch is changed, the second component stays affixed to the skin for a few days. Additionally, some bags feature exit drains for liquid outflow (ileostomies, for example). The smell of flatus can be lessened by using charcoal filters.
Investigations
Pre-op: Stoma placement and counseling are crucial, however they aren't always feasible in emergency cases. Specialist nurses in stoma care are essential. Pre-operative stomas should be identified so the patient can see it; skinfolds, scars, bony prominences, and the belt line should all be avoided. You might need to prepare your intestines. It is frequently necessary to have distal contrast investigations before stoma reversal. Prophylactic DVT after surgery. Support and education for patients in managing their stomas.
Procedure
Skin incision: A circular skin incision is made at the designated stoma site (using the rectus muscle to place a stoma reduces the risk of parastomal hernia development). A cut is made in the skin, the fascia is separated, the muscle is split, and the peritoneum is opened (to allow room for two fingers).
Formation of a stoma: The bowel's loop or end is brought out through the aperture. This gut should be well-vascularized, stress-free, and trauma-free. The primary incision has been treated and sealed. If the bowel is a loop or has been stapled in the past, it is opened, and the edges are cleansed. The bowel is turned inside out and the skin is sutured around the margins. Next, a transparent stoma bag is placed to enable routine stoma examination.
Complications
40% for ileostomies and 20% for colostomies, with 15% requiring surgical repair, are relatively common.
Death: becomes apparent a few hours after surgery and necessitates stoma modification because it compromises the bowel's blood flow during stoma development.
Haemorrhage: In most cases, only little bleeding needs medical attention. Practical: either constipation or diarrhea. Large volume liquid output from ileostomies can cause electrolyte imbalances and dehydration, which can be treated with fluid replacement and prescription drugs like codeine and loperamide. Hydration is crucial because urinary tract calculi are more likely in those who have an ileostomy.
Additional conditions include skin irritation, leaks, prolapses or retractions that occasionally need to be refashioned, stenosis (which can sometimes be widened using a dilator), parastomal hernias, abscesses, or fistulas.
Psychological: Anxiety, shame, or issues with body image.
Indications for Stomas
an incision made in surgery that connects the bladder or intestine to a bodily surface. Ileostomy, colostomy, and urostomy are the most common types of stomas; oesophagostomy, gastrostomy, jejunostomy, and caecostomy are among the others. End or loop stomas, either permanent or temporary. Malignancy in inflammatory bowel disease is optional. After a panproctocolectomy for familial polyposis or ulcerative colitis, stop ileostomies. following abdominoperineal excision for low rectal carcinomas, permanent colostomies. Loop stomas are used to temporarily divert bowel contents from sick sections of the intestines in order to safeguard distal surgery, such as an ileoanal pouch or low colorectal anastomosis, or to restore the anal sphincter.
Emergency: Ischemic bowel illness, inflammatory bowel damage, perforation, blockage, and toxic megacolon. During a Hartmann procedure, the distal end of the divided bowel is sealed or made into a mucous fistula, and the diseased distal colon is removed with the creation of an end colostomy.
Anatomy
End stoma: To create the stoma, the colon is divided and its proximal end is brought through the abdominal wall. The distal end can form a double barrel stoma in the same opening, be closed and left in the belly, or be brought out through a different incision called a mucous fistula.
Loop stomas: A stoma with two lumens is created by raising a bowel loop to the surface, opening it, then folding it back on itself. may be simpler to shut. A certain amount of "spillover" of the nearest contents.
Ileostomies: Located in the right iliac fossa, albeit not necessarily. They are designed with a spout that protrudes 2.5 cm above the skin's surface because the discharge is irritating. Liquid output occurs at a rate of 1-2 L per day, however it may decrease after a few weeks.
Colostomies: The stoma is flush with the skin and is typically located in the LIF, though it can be anywhere. Depending on the diet, the output is sporadic and has a more solid consistency (although transverse colostomies can produce semi-liquid, which can be more challenging to control).
Appliances for stomas: Comprised of a flange, which covers and shields the skin surrounding the stoma, and a pouch. There could be one or two pieces in the flange; when the pouch is changed, the second component stays affixed to the skin for a few days. Additionally, some bags feature exit drains for liquid outflow (ileostomies, for example). The smell of flatus can be lessened by using charcoal filters.
Investigations
Pre-op: Stoma placement and counseling are crucial, however they aren't always feasible in emergency cases. Specialist nurses in stoma care are essential. Pre-operative stomas should be identified so the patient can see it; skinfolds, scars, bony prominences, and the belt line should all be avoided. You might need to prepare your intestines. It is frequently necessary to have distal contrast investigations before stoma reversal. Prophylactic DVT after surgery. Support and education for patients in managing their stomas.
Procedure
Skin incision: A circular skin incision is made at the designated stoma site (using the rectus muscle to place a stoma reduces the risk of parastomal hernia development). A cut is made in the skin, the fascia is separated, the muscle is split, and the peritoneum is opened (to allow room for two fingers).
Formation of a stoma: The bowel's loop or end is brought out through the aperture. This gut should be well-vascularized, stress-free, and trauma-free. The primary incision has been treated and sealed. If the bowel is a loop or has been stapled in the past, it is opened, and the edges are cleansed. The bowel is turned inside out and the skin is sutured around the margins. Next, a transparent stoma bag is placed to enable routine stoma examination.
Complications
40% for ileostomies and 20% for colostomies, with 15% requiring surgical repair, are relatively common.
Death: becomes apparent a few hours after surgery and necessitates stoma modification because it compromises the bowel's blood flow during stoma development.
Haemorrhage: In most cases, only little bleeding needs medical attention. Practical: either constipation or diarrhea. Large volume liquid output from ileostomies can cause electrolyte imbalances and dehydration, which can be treated with fluid replacement and prescription drugs like codeine and loperamide. Hydration is crucial because urinary tract calculi are more likely in those who have an ileostomy.
Additional conditions include skin irritation, leaks, prolapses or retractions that occasionally need to be refashioned, stenosis (which can sometimes be widened using a dilator), parastomal hernias, abscesses, or fistulas.
Psychological: Anxiety, shame, or issues with body image.
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Surgery - Suturing
Indications
surgical cuts or wounds that need to be closed. In order to promote quick healing and optimal cosmesis, the goal is to align the edges of the wounds without stress.
Anatomy
The epidermis, or outside keratinized epithelium, the dermis, or underlying fibroelastic layer containing blood vessels, lymphatics, and nerves, and the subcutaneous tissue, or deep layer of varying thickness made up primarily of adipose tissue, are the three layers that make up the skin.
Investigations
Prior to surgery: history of allergies to skin prep or antibiotics; informed consent. Proper cleansing and dressing of severe injuries. It is imperative to take into account one's tetanus status and administer booster shots or immunoglobulins as necessary, along with vaccinations. If there is a chance of a foreign body, such glass, or a related bone damage, radiographs can be required.
Advice on wound care, analgesics, dressings, and antibiotics only when necessary follow surgery.
Procedure
Simple cuts may mostly be closed.It is advisable to refer patients with more complicated injuries—such as those involving the face or other traumas, such tendon damage—to the proper specialists, like plastic surgeons. Antibiotics should be used if linked to a fracture, namely an open fracture. Primary closure is avoided and antibiotics are used for bite wounds, particularly those resulting from bites on humans.
Local anaesthesia: After skin preparation, the area surrounding the wound is infused with local anesthetic, being sure to aspirate before injecting to prevent intravascular injection. It is never advisable to inject local anesthetic combined with adrenaline close to fingers or in regions like the nose, ear, or penis.
Examining and cleaning the wound: The wound is carefully cleaned, irrigated, and inspected. It could need to be scrubbed if it's dirty. The wound is examined to look for any underlying injuries, such as to tendons.
Sutures can be categorized as either natural or synthetic, absorbable or non-absorbable, and as single or multifilament (braided). Subcutaneous absorbable sutures are utilized when suturing deep tissues. In traumatic wounds, non-absorbable sutures are always employed. This prevents the entire wound from being compromised in the event that an infection occurs, allowing for the removal of one or a small number.
In surgical wounds, absorbable sutures are frequently utilized. A finer 5–0 or 6–0 stitch for the face, 3–0 or 4–0 for the trunk and limbs, and 2–0 for the scalp are the types of sutures that are utilized depending on the place.
Suturing: For a diagrammatic description of types, see to Fig. 26. When using aseptic method, wounds should be properly prepped and draped. Simple discontinuous (broken) sutures are frequently employed. For deeper wounds, vertical mattress stitches may be employed because they allow for adequate skin edge eversion.
Good cosmesis and close wound approximation are made possible by subcuticular suturing.
Dressing: The wound is covered with a dry dressing. Only as long as necessary is the length of time that stitches are left in place to maintain the incision. Face stitches come out in a matter of two to five days, but sutures on the limbs and abdominal wall typically take ten days to fall out.
Complications
Inadequate aesthetics: sutures may serve as a breeding ground for infection, abscess, granuloma, sinus, wound dehiscence, and scarring.
Indications
surgical cuts or wounds that need to be closed. In order to promote quick healing and optimal cosmesis, the goal is to align the edges of the wounds without stress.
Anatomy
The epidermis, or outside keratinized epithelium, the dermis, or underlying fibroelastic layer containing blood vessels, lymphatics, and nerves, and the subcutaneous tissue, or deep layer of varying thickness made up primarily of adipose tissue, are the three layers that make up the skin.
Investigations
Prior to surgery: history of allergies to skin prep or antibiotics; informed consent. Proper cleansing and dressing of severe injuries. It is imperative to take into account one's tetanus status and administer booster shots or immunoglobulins as necessary, along with vaccinations. If there is a chance of a foreign body, such glass, or a related bone damage, radiographs can be required.
Advice on wound care, analgesics, dressings, and antibiotics only when necessary follow surgery.
Procedure
Simple cuts may mostly be closed.It is advisable to refer patients with more complicated injuries—such as those involving the face or other traumas, such tendon damage—to the proper specialists, like plastic surgeons. Antibiotics should be used if linked to a fracture, namely an open fracture. Primary closure is avoided and antibiotics are used for bite wounds, particularly those resulting from bites on humans.
Local anaesthesia: After skin preparation, the area surrounding the wound is infused with local anesthetic, being sure to aspirate before injecting to prevent intravascular injection. It is never advisable to inject local anesthetic combined with adrenaline close to fingers or in regions like the nose, ear, or penis.
Examining and cleaning the wound: The wound is carefully cleaned, irrigated, and inspected. It could need to be scrubbed if it's dirty. The wound is examined to look for any underlying injuries, such as to tendons.
Sutures can be categorized as either natural or synthetic, absorbable or non-absorbable, and as single or multifilament (braided). Subcutaneous absorbable sutures are utilized when suturing deep tissues. In traumatic wounds, non-absorbable sutures are always employed. This prevents the entire wound from being compromised in the event that an infection occurs, allowing for the removal of one or a small number.
In surgical wounds, absorbable sutures are frequently utilized. A finer 5–0 or 6–0 stitch for the face, 3–0 or 4–0 for the trunk and limbs, and 2–0 for the scalp are the types of sutures that are utilized depending on the place.
Suturing: For a diagrammatic description of types, see to Fig. 26. When using aseptic method, wounds should be properly prepped and draped. Simple discontinuous (broken) sutures are frequently employed. For deeper wounds, vertical mattress stitches may be employed because they allow for adequate skin edge eversion.
Good cosmesis and close wound approximation are made possible by subcuticular suturing.
Dressing: The wound is covered with a dry dressing. Only as long as necessary is the length of time that stitches are left in place to maintain the incision. Face stitches come out in a matter of two to five days, but sutures on the limbs and abdominal wall typically take ten days to fall out.
Complications
Inadequate aesthetics: sutures may serve as a breeding ground for infection, abscess, granuloma, sinus, wound dehiscence, and scarring.
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Surgery - Thyroidectomy
Indications
When a FNA is unclear, a thyroid mass can be definitively diagnosed as either benign or malignant. Symptomatic goiters (cosmesis or pressure effects). as a treatment for toxic nodular goitre, graves disease, or thyrotoxicosis.
Anatomy
The thyroid isthmus, which sits above the second and third tracheal rings, connects the thyroid gland's two lobes. The gland is located deep to the strap muscles and is encased in the pretracheal fascia.
Vascular: The gland is supplied by the lower thyroid artery from the subclavian thyrocervical trunk, the superior thyroid artery from the external carotid, and occasionally the thyroidea ima artery from the brachiocephalic or aortic arch. The internal jugular vein receives venous drainage from the superior, middle, and inferior thyroid veins.
Investigations
Bloods: Complete blood count, renal function, calcium, and thyroid function tests. Patients with hypo- or hyperthyroidism should receive medical treatment prior to surgery.
Ultrasound: To identify a goiter or characterize a lesion. To evaluate tracheal constriction and retrosternal extension, use a CT scan. scintigraphy in nuclear medicine, where applicable.
FNA or biopsy guided by ultrasound: For cytological diagnosis.
Indirect laryngoscopy: To evaluate vocal cord health prior to surgery.
After surgery: Continue to monitor and replace calcium as needed. replacement of thyroid.
Procedure
Head up, neck stretched, in a reverse Trendelenburg position.
Incision: Two fingerbreadths above the suprasternal notch, in the skin crease collar.
To prevent harm to the anterior jugular veins, subcutaneous tissue and platysma are split, and flaps are elevated superiorly to the thyroid cartilage and inferiorly to the sternum.
Thyroid exposure and mobilization: The subplatysma flaps are retracted using a Jolls retractor. To reveal the thyroid gland underneath, the midline raphe is divided, separating the strap muscles. The thyroid gland is visible. Carefully ligating the middle thyroid vein(s) involves locating and avoiding parathyroids, which are little tan glands. The vessels in the superior pole are separated, snipped off from the gland, and double ligated. The tracheooesophageal groove contains the recurrent laryngeal nerve, which needs to be properly identified and protected to prevent diathermy in the area around it. Though it normally runs between or in front of the lower pole vessels, it is usually deep. The thyroid is properly ligated in close proximity to the inferior thyroid vascular pedicle. Absorbable sutures are used to oversew the isthmus in cases of hemithyroidectomy.
Close: Maintaining proper hemostasis is crucial. A lot of surgeons choose to leave a vacuum drain in place.
Three layers make up the closure: the skin, platysma, subcutaneous tissue, and the opposition of the strap muscles.
Complications
Bleeding, hypocalcemia, hypothyroidism, wound infection, vocal abnormalities due to recurrent laryngeal nerve injury, breathing difficulties brought on by a hemorrhage compressing the trachea or bilaterally.
Indications
When a FNA is unclear, a thyroid mass can be definitively diagnosed as either benign or malignant. Symptomatic goiters (cosmesis or pressure effects). as a treatment for toxic nodular goitre, graves disease, or thyrotoxicosis.
Anatomy
The thyroid isthmus, which sits above the second and third tracheal rings, connects the thyroid gland's two lobes. The gland is located deep to the strap muscles and is encased in the pretracheal fascia.
Vascular: The gland is supplied by the lower thyroid artery from the subclavian thyrocervical trunk, the superior thyroid artery from the external carotid, and occasionally the thyroidea ima artery from the brachiocephalic or aortic arch. The internal jugular vein receives venous drainage from the superior, middle, and inferior thyroid veins.
Investigations
Bloods: Complete blood count, renal function, calcium, and thyroid function tests. Patients with hypo- or hyperthyroidism should receive medical treatment prior to surgery.
Ultrasound: To identify a goiter or characterize a lesion. To evaluate tracheal constriction and retrosternal extension, use a CT scan. scintigraphy in nuclear medicine, where applicable.
FNA or biopsy guided by ultrasound: For cytological diagnosis.
Indirect laryngoscopy: To evaluate vocal cord health prior to surgery.
After surgery: Continue to monitor and replace calcium as needed. replacement of thyroid.
Procedure
Head up, neck stretched, in a reverse Trendelenburg position.
Incision: Two fingerbreadths above the suprasternal notch, in the skin crease collar.
To prevent harm to the anterior jugular veins, subcutaneous tissue and platysma are split, and flaps are elevated superiorly to the thyroid cartilage and inferiorly to the sternum.
Thyroid exposure and mobilization: The subplatysma flaps are retracted using a Jolls retractor. To reveal the thyroid gland underneath, the midline raphe is divided, separating the strap muscles. The thyroid gland is visible. Carefully ligating the middle thyroid vein(s) involves locating and avoiding parathyroids, which are little tan glands. The vessels in the superior pole are separated, snipped off from the gland, and double ligated. The tracheooesophageal groove contains the recurrent laryngeal nerve, which needs to be properly identified and protected to prevent diathermy in the area around it. Though it normally runs between or in front of the lower pole vessels, it is usually deep. The thyroid is properly ligated in close proximity to the inferior thyroid vascular pedicle. Absorbable sutures are used to oversew the isthmus in cases of hemithyroidectomy.
Close: Maintaining proper hemostasis is crucial. A lot of surgeons choose to leave a vacuum drain in place.
Three layers make up the closure: the skin, platysma, subcutaneous tissue, and the opposition of the strap muscles.
Complications
Bleeding, hypocalcemia, hypothyroidism, wound infection, vocal abnormalities due to recurrent laryngeal nerve injury, breathing difficulties brought on by a hemorrhage compressing the trachea or bilaterally.
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Surgery - Tracheostomy
Indications
Longer-term ventilatory support (or weaning) is the most prevalent indication; additional conditions include head and neck surgery, neurological impairment (such as coma, stroke, and motor neurone disease), trauma, and bilateral vocal cord paralysis.
Anatomy
The posterior (membranous) portion of the trachea is composed of incomplete semicircular cartilage rings. The front surface of the trachea is convex and is covered (superiorly to inferiorly) by the cervical fascia, the inferior thyroid veins, the thyroid gland's isthmus (over the second and third rings), and the neck's strap muscles. The inferior thyroid veins and recurrent laryngeal nerves are located laterally in the tracheooesophageal grooves and are susceptible to damage.
A tracheostomy can be cuffed or uncuffed, made of plastic, silicone, or metal, or fenestrated, which permits speech since the tube has a hole that lets air pass through the upper airway in the event that the external opening is blocked. Most have an obdurator that facilitates insertion but is removed once in place, an exterior cannula, and an interior cannula.
Investigations
carried out while under general anesthesia.
Pre-procedure: Pre-procedure counseling regarding risks and benefits is advised whenever it is feasible.
After surgery, meticulous attention is necessary. Regular sterile suction of retained secretions along with humidified gases. Positive pressure breathing is possible with cuffed tracheal tubes, although pressure necrosis can be avoided by routinely monitoring and deflating the tube. The tracheostomy tube can be changed after 5-7 days.
Actions
Access: The patient's neck is stretched in this position. In the middle of the cricoid cartilage and the sternal notch, a vertical or transverse incision is made. In order to reveal the trachea, cut through the platysma and subcutaneous tissue, split and retract the strap muscles, and separate the thyroid isthmus if required.
Surgical tracheostomy: Cut the trachea longitudinally or in a U-shape, creating two to three tracheal rings. In order to facilitate replacement in the event that the tracheostomy tube becomes dislodged, stay sutures can be positioned laterally to aid in maintaining the trachea open.
Put in a tracheostomy tube (removing the endotracheal tube at the same time might be required). The tracheostomy tube's balloon should be inflated before being sutured to the skin.
In ITU/HDU settings, percutaneous tracheostomy can be carried out. uses a bronchoscope and the Seldinger technique to create a percutaneous tracheal cannulation. A guidewire and progressive dilators are then inserted before the tracheostomy tube is inserted. Patients with complex anatomy, obesity, coagulopathy, or thyroid enlargement should not use this treatment.
Complications
Short-term: bleeding, infection, subcutaneous emphysema, pneumothorax or pneumomediastinum, damage to surrounding structures, such as oesophagus, arteries, recurrent laryngeal nerves, tube displacement, tracheal ulcers, tracheitis, mucus plugging, aspiration.
Prolonged: tracheomalacia, overgranulation, tracheo-oesophageal fistula (<1%), tracheocutaneous fistula, tracheal stenosis.
Indications
Longer-term ventilatory support (or weaning) is the most prevalent indication; additional conditions include head and neck surgery, neurological impairment (such as coma, stroke, and motor neurone disease), trauma, and bilateral vocal cord paralysis.
Anatomy
The posterior (membranous) portion of the trachea is composed of incomplete semicircular cartilage rings. The front surface of the trachea is convex and is covered (superiorly to inferiorly) by the cervical fascia, the inferior thyroid veins, the thyroid gland's isthmus (over the second and third rings), and the neck's strap muscles. The inferior thyroid veins and recurrent laryngeal nerves are located laterally in the tracheooesophageal grooves and are susceptible to damage.
A tracheostomy can be cuffed or uncuffed, made of plastic, silicone, or metal, or fenestrated, which permits speech since the tube has a hole that lets air pass through the upper airway in the event that the external opening is blocked. Most have an obdurator that facilitates insertion but is removed once in place, an exterior cannula, and an interior cannula.
Investigations
carried out while under general anesthesia.
Pre-procedure: Pre-procedure counseling regarding risks and benefits is advised whenever it is feasible.
After surgery, meticulous attention is necessary. Regular sterile suction of retained secretions along with humidified gases. Positive pressure breathing is possible with cuffed tracheal tubes, although pressure necrosis can be avoided by routinely monitoring and deflating the tube. The tracheostomy tube can be changed after 5-7 days.
Actions
Access: The patient's neck is stretched in this position. In the middle of the cricoid cartilage and the sternal notch, a vertical or transverse incision is made. In order to reveal the trachea, cut through the platysma and subcutaneous tissue, split and retract the strap muscles, and separate the thyroid isthmus if required.
Surgical tracheostomy: Cut the trachea longitudinally or in a U-shape, creating two to three tracheal rings. In order to facilitate replacement in the event that the tracheostomy tube becomes dislodged, stay sutures can be positioned laterally to aid in maintaining the trachea open.
Put in a tracheostomy tube (removing the endotracheal tube at the same time might be required). The tracheostomy tube's balloon should be inflated before being sutured to the skin.
In ITU/HDU settings, percutaneous tracheostomy can be carried out. uses a bronchoscope and the Seldinger technique to create a percutaneous tracheal cannulation. A guidewire and progressive dilators are then inserted before the tracheostomy tube is inserted. Patients with complex anatomy, obesity, coagulopathy, or thyroid enlargement should not use this treatment.
Complications
Short-term: bleeding, infection, subcutaneous emphysema, pneumothorax or pneumomediastinum, damage to surrounding structures, such as oesophagus, arteries, recurrent laryngeal nerves, tube displacement, tracheal ulcers, tracheitis, mucus plugging, aspiration.
Prolonged: tracheomalacia, overgranulation, tracheo-oesophageal fistula (<1%), tracheocutaneous fistula, tracheal stenosis.
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Surgery - Liver Resection
Indications
Elective: Liver tumors: primary and secondary, benign and malignant.
Guidelines regarding colorectal metastases: liver disease that can be completely removed with a resection margin of greater than 5 mm, leaving at least three normal liver segments (or more if cirrhosis), solitary or metastases restricted to a localized area of the liver, without extrahepatic disease or limited to resectable local recurrence.
Infections: Some infections, such hydatid cysts, may require excision.
Live-related liver donation is removing a portion of the donor's liver and transplanting the recipient with the removed liver.
Trauma in an emergency if measures like packing, suture ligation, or bimanual compression have not been able to stop the bleeding (resectional debridement of devitalized liver tissue, for example).
Anatomy
The liver is divided into eight segments (of Couinaud), each with its own branches of the arterial, venous, and biliary systems. The liver has four lobes: the right, left, quadrate, and caudate (the latter two physically part of the right lobe but functionally part of the left). I through VIII are their numbers (from left to right). Segmental or nonsegmental resections are possible. Normal humans can regenerate up to 70% of their body, which is consistent with survival.
Vascular supply: The portal vein (70%) and hepatic artery (30%) each supply 1.5 liters of blood per minute to the liver. The inferior vena cava receives the three hepatic veins that are formed by venous flow.
Investigational studies
Patients must be chosen based on stringent qualifying requirements.
Imaging: USS, CT, and MRI may be required for resection planning and staging.
Liver function before to surgery: As an illustration, children–Pugh grading (based on prothrombin time, bilirubin, albumin, and the presence of ascites or encephalopathy): because of the small reserve of the remnant cirrhotic liver, cirrhosis prevents major resections.
Blood: LFT, clotting, U&Es, and FBC.
Blood-based products: Before surgery, blood and FFP should be cross-matched because to the increased risk of bleeding and the need for transfusions.
Actions
should only be completed in facilities with the necessary expertise as specialists.
Rooftop incisions or increasingly laparoscopic procedures are used for incisions.
Investigation: Using intraoperative ultrasound, a tumor's boundaries and the extent to which it has affected nearby structures (such as the biliary tree and arteries) can be determined.
Vascular occlusion: Two methods are used to temporarily obstruct the inflow into the liver: either the Glisson's capsule of the segment is selectively clamped, or a tourniquet is placed around the portal triad (Pringle's technique, up to 20 min).
Liver resection: A variety of procedures, such as the use of an ultrasonic dissector and harmonic scalpel to carefully ligate sutures or cut arteries or ducts, can be used to achieve parenchymal transaction. Lastly, a thorough inspection for bleeding or bile leakage should be performed on the resection surface.
Closure of the liver: Resection surfaces can be sealed using fibrin adhesive or a collagen sponge.
Complications
bleeding, liver failure, biliary or peritonitis-related sepsis, and related pulmonary problems (such as pleural effusion).
Indications
Elective: Liver tumors: primary and secondary, benign and malignant.
Guidelines regarding colorectal metastases: liver disease that can be completely removed with a resection margin of greater than 5 mm, leaving at least three normal liver segments (or more if cirrhosis), solitary or metastases restricted to a localized area of the liver, without extrahepatic disease or limited to resectable local recurrence.
Infections: Some infections, such hydatid cysts, may require excision.
Live-related liver donation is removing a portion of the donor's liver and transplanting the recipient with the removed liver.
Trauma in an emergency if measures like packing, suture ligation, or bimanual compression have not been able to stop the bleeding (resectional debridement of devitalized liver tissue, for example).
Anatomy
The liver is divided into eight segments (of Couinaud), each with its own branches of the arterial, venous, and biliary systems. The liver has four lobes: the right, left, quadrate, and caudate (the latter two physically part of the right lobe but functionally part of the left). I through VIII are their numbers (from left to right). Segmental or nonsegmental resections are possible. Normal humans can regenerate up to 70% of their body, which is consistent with survival.
Vascular supply: The portal vein (70%) and hepatic artery (30%) each supply 1.5 liters of blood per minute to the liver. The inferior vena cava receives the three hepatic veins that are formed by venous flow.
Investigational studies
Patients must be chosen based on stringent qualifying requirements.
Imaging: USS, CT, and MRI may be required for resection planning and staging.
Liver function before to surgery: As an illustration, children–Pugh grading (based on prothrombin time, bilirubin, albumin, and the presence of ascites or encephalopathy): because of the small reserve of the remnant cirrhotic liver, cirrhosis prevents major resections.
Blood: LFT, clotting, U&Es, and FBC.
Blood-based products: Before surgery, blood and FFP should be cross-matched because to the increased risk of bleeding and the need for transfusions.
Actions
should only be completed in facilities with the necessary expertise as specialists.
Rooftop incisions or increasingly laparoscopic procedures are used for incisions.
Investigation: Using intraoperative ultrasound, a tumor's boundaries and the extent to which it has affected nearby structures (such as the biliary tree and arteries) can be determined.
Vascular occlusion: Two methods are used to temporarily obstruct the inflow into the liver: either the Glisson's capsule of the segment is selectively clamped, or a tourniquet is placed around the portal triad (Pringle's technique, up to 20 min).
Liver resection: A variety of procedures, such as the use of an ultrasonic dissector and harmonic scalpel to carefully ligate sutures or cut arteries or ducts, can be used to achieve parenchymal transaction. Lastly, a thorough inspection for bleeding or bile leakage should be performed on the resection surface.
Closure of the liver: Resection surfaces can be sealed using fibrin adhesive or a collagen sponge.
Complications
bleeding, liver failure, biliary or peritonitis-related sepsis, and related pulmonary problems (such as pleural effusion).
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Surgery - Liver Transplantation
Indications
In the UK, between 600 and 700 liver transplants are performed each year in accredited facilities offering interdisciplinary care.
Elective: For end-stage liver disease, such as cirrhosis, which can lead to complications such diuretic-resistant ascites, recurrent spontaneous bacterial peritonitis, hepatorenal syndrome, and recurrent varicella hemorrhage. Biliary atresia is the most typical sign in children. The Model for End-Stage Liver Disease (MELD) scoring system, which is based on bilirubin, creatinine, and INR, or the Pediatric End-Stage Liver Disease scoring system, which is based on albumin, bilirubin, INR, growth failure, and age at listing, determine the severity of the condition before allocating organs. When diagnosing hepatocellular cancer, the "Milan criteria" are applied: one tumor <5 cm or three lesions <3 cm.
Emergency: Acute liver failure, with paracetamol overdose, viral hepatitis, and peculiar medication reactions being the most frequent causes.
Anatomy
Orthoptic transplantation, often known as liver transplantation, is removing the damaged liver and replacing it with a graft in the natural hepatic bed. Although the recipient's vena cava is preserved using a different method called the "piggyback" approach, the retrohepatic part of the inferior vena cava is typically removed along with the recipient's liver. Splitting adult donor organs and segmental liver transplantation (e.g., segments 2 and 3) are done on minors.
Investigations
Pre-op: Before being put on the waiting list, patients have a thorough and in-depth examination. This comprises an ECG and echocardiography database, liver biopsy, blood grouping, tissue typing, ABG, imaging (USS, CT scans of the abdomen, head, and chest), and other evaluations, such as reviews of dentistry and psychiatry. Following organ allocation, the patient undergoes sepsis screening using ascitic tap, CXR, MSU, and blood cultures.
After surgery: Initial care involves intensive observation, antibiotics, and immunosuppression in an intensive care unit.
Procedure
The majority of donated organs come from heart-pounding individuals who have experienced brainstem death.
There are currently no objective markers of liver quality or status; instead, surgeons' subjective assessments of the liver's texture and fat content are used. The use of living relatives as donors is growing; one example is the donor's right hemihepatectomy. Blood type and weight are used to match donors and recipients.
Organ retrieval: Takes place when retrieving many organs. The hepatic artery, portal vein, bile duct, and supra- and infrahepatic IVC are dissected once the liver is mobilized. The University of Wisconsin solution or another cold preservation solution is quickly infused into the liver by cannulas placed into the portal vein and aortic arteries. The biliary system is flushed with a preservative solution after the liver and its related arteries are removed. The maximum storage duration is 15–18 hours; the shorter the preservation period, the better the outcomes.
Recipient operation: Due to related portal hypertension and coagulation problems, this procedure is frequently technically challenging. Blood product transfusions need close, intrusive monitoring; however, this can be minimized by using a cell saver, which gathers, cleans, and reuses red blood cells.
Access is gained through a "Mercedes-Benz incision." The bile duct and vasculature are severed, and the liver is mobilized.
Hepatectomy: Recipient hepatectomy entails clamping the IVC. Veno-venous bypass is employed to divert flow from the IVC, returning via an axillary or jugular vein, in patients who are unlikely to tolerate the ensuing drop in cardiac output.
Graft anastomosis: The donor liver is then anastomosed end-to-end or over a T-tube into the bile duct via the portal vein, hepatic artery, suprahepatic IVC, and infrahepatic IVC. It may be necessary to execute a Roux-en-Y choledochoenterostomy if the recipient bile duct is diseased.
Immunosuppression: Usually involves the use of an antimetabolite, such as mycophenolate mofetil, together with a calcineurin inhibitor, such as tacrolimus along with corticosteroids. LFT monitoring and transplanted liver biopsy (often through transjugular route) are used to screen for rejection.
Complications
<7% of first grafts fail or fail to function, which is a significant problem that necessitates retransplantation.
Vascular: Portal vein thrombosis, hepatic artery thrombosis, and hemorrhage are rare examples.
Biliary: Anastomotic stenosis followed by bile leakage.
Opportunistic infections: CMV and fungal infections are examples of infections.
Rejecting: Acute: Often brought on by T cells fighting the graft, this condition is managed with IV steroid shots or antibody therapy (antithymocyte globulin).
Chronic (less than 5%): Develops after the first year and is linked to progressively worsening jaundice.
Histology reveals tiny artery occlusions and "vanishing bile ducts," which typically necessitate retransplantation.
Recurrent liver disease: Reinfection is typical in cases of hepatitis B or C (if the infection was first present), with the latter potentially developing aggressively and quickly.
Hepatitis B can be treated with immunization and HB-Ig. In addition to autoimmune hepatitis, PBC, PSC, and recidivism in cases of alcoholic liver disease, there are other diseases that can recur.
Immunosuppressive complications include drug side effects, infections, diabetes, and post-transplant tumors, such as lymphomas and skin cancers.
Prognosis
Overall, survival rates are high, standing at 85% after a year and 70% after ten.
Indications
In the UK, between 600 and 700 liver transplants are performed each year in accredited facilities offering interdisciplinary care.
Elective: For end-stage liver disease, such as cirrhosis, which can lead to complications such diuretic-resistant ascites, recurrent spontaneous bacterial peritonitis, hepatorenal syndrome, and recurrent varicella hemorrhage. Biliary atresia is the most typical sign in children. The Model for End-Stage Liver Disease (MELD) scoring system, which is based on bilirubin, creatinine, and INR, or the Pediatric End-Stage Liver Disease scoring system, which is based on albumin, bilirubin, INR, growth failure, and age at listing, determine the severity of the condition before allocating organs. When diagnosing hepatocellular cancer, the "Milan criteria" are applied: one tumor <5 cm or three lesions <3 cm.
Emergency: Acute liver failure, with paracetamol overdose, viral hepatitis, and peculiar medication reactions being the most frequent causes.
Anatomy
Orthoptic transplantation, often known as liver transplantation, is removing the damaged liver and replacing it with a graft in the natural hepatic bed. Although the recipient's vena cava is preserved using a different method called the "piggyback" approach, the retrohepatic part of the inferior vena cava is typically removed along with the recipient's liver. Splitting adult donor organs and segmental liver transplantation (e.g., segments 2 and 3) are done on minors.
Investigations
Pre-op: Before being put on the waiting list, patients have a thorough and in-depth examination. This comprises an ECG and echocardiography database, liver biopsy, blood grouping, tissue typing, ABG, imaging (USS, CT scans of the abdomen, head, and chest), and other evaluations, such as reviews of dentistry and psychiatry. Following organ allocation, the patient undergoes sepsis screening using ascitic tap, CXR, MSU, and blood cultures.
After surgery: Initial care involves intensive observation, antibiotics, and immunosuppression in an intensive care unit.
Procedure
The majority of donated organs come from heart-pounding individuals who have experienced brainstem death.
There are currently no objective markers of liver quality or status; instead, surgeons' subjective assessments of the liver's texture and fat content are used. The use of living relatives as donors is growing; one example is the donor's right hemihepatectomy. Blood type and weight are used to match donors and recipients.
Organ retrieval: Takes place when retrieving many organs. The hepatic artery, portal vein, bile duct, and supra- and infrahepatic IVC are dissected once the liver is mobilized. The University of Wisconsin solution or another cold preservation solution is quickly infused into the liver by cannulas placed into the portal vein and aortic arteries. The biliary system is flushed with a preservative solution after the liver and its related arteries are removed. The maximum storage duration is 15–18 hours; the shorter the preservation period, the better the outcomes.
Recipient operation: Due to related portal hypertension and coagulation problems, this procedure is frequently technically challenging. Blood product transfusions need close, intrusive monitoring; however, this can be minimized by using a cell saver, which gathers, cleans, and reuses red blood cells.
Access is gained through a "Mercedes-Benz incision." The bile duct and vasculature are severed, and the liver is mobilized.
Hepatectomy: Recipient hepatectomy entails clamping the IVC. Veno-venous bypass is employed to divert flow from the IVC, returning via an axillary or jugular vein, in patients who are unlikely to tolerate the ensuing drop in cardiac output.
Graft anastomosis: The donor liver is then anastomosed end-to-end or over a T-tube into the bile duct via the portal vein, hepatic artery, suprahepatic IVC, and infrahepatic IVC. It may be necessary to execute a Roux-en-Y choledochoenterostomy if the recipient bile duct is diseased.
Immunosuppression: Usually involves the use of an antimetabolite, such as mycophenolate mofetil, together with a calcineurin inhibitor, such as tacrolimus along with corticosteroids. LFT monitoring and transplanted liver biopsy (often through transjugular route) are used to screen for rejection.
Complications
<7% of first grafts fail or fail to function, which is a significant problem that necessitates retransplantation.
Vascular: Portal vein thrombosis, hepatic artery thrombosis, and hemorrhage are rare examples.
Biliary: Anastomotic stenosis followed by bile leakage.
Opportunistic infections: CMV and fungal infections are examples of infections.
Rejecting: Acute: Often brought on by T cells fighting the graft, this condition is managed with IV steroid shots or antibody therapy (antithymocyte globulin).
Chronic (less than 5%): Develops after the first year and is linked to progressively worsening jaundice.
Histology reveals tiny artery occlusions and "vanishing bile ducts," which typically necessitate retransplantation.
Recurrent liver disease: Reinfection is typical in cases of hepatitis B or C (if the infection was first present), with the latter potentially developing aggressively and quickly.
Hepatitis B can be treated with immunization and HB-Ig. In addition to autoimmune hepatitis, PBC, PSC, and recidivism in cases of alcoholic liver disease, there are other diseases that can recur.
Immunosuppressive complications include drug side effects, infections, diabetes, and post-transplant tumors, such as lymphomas and skin cancers.
Prognosis
Overall, survival rates are high, standing at 85% after a year and 70% after ten.
- Published on
Surgery - Mastectomy
Indications
When lumpectomy alone is unable to achieve tumour-free margins, in situ carcinoma or multifocal tumours, patient preference, tumours fixed to underlying muscle, skin, or fungal with accompanying ulceration or bleeding, and bilateral prophylactic mastectomy (e.g., patients carrying the BRCA-1 or BRCA-2 genes) are among the indications for mastectomy in breast cancer cases.
Anatomy
There is a complex network of branching milk ducts that exit on the nipple (from 4 to 18 ducts; the anatomy originally reported by Cooper has been substantially changed in recent years). The breast tissue is composed of fatty and glandular tissue (ratio ranges from 1: 1 to 1: 2 in lactation). With an axillary tail, the base of the breast encloses the second through sixth ribs. Suspensory connective tissue ligaments support the breast tissue by extending from the dermis to the deep fascia.
Vascular: The internal mammary, intercostal, thoracodorsal, lateral thoracic, and thoracoacromial arteries, as well as their perforating arteries, provide the breast's arterial supply and associated venous drainage.
The lymphatic system While the medial half drains into the nodes along the internal mammary artery, the lateral half's lymphatics drain into the axillary nodes, which are made up of the anterior, posterior, lateral, central, and apical groups.
Investigations
Prior to surgery: A triple assessment of the clinical examination, imaging (mammography, ultrasound, or MRI scan), and cytology/histological analysis by FNA or trucut biopsy is used to diagnose tumors. Before a mastectomy, a biopsy should ideally confirm malignancy.
Investigation staging: CT, PET, ultrasonography, bone scans, and CXR scans can all be carried out.
Downsizing the tumor may be accomplished by neoadjuvant chemotherapy.
Blood tests: G&S, clotting, FBC, U&Es, LFT, or crossmatch. general evaluation of anesthesia.
Following surgery: bra insert fitting, DVT prophylaxis, analgesia, physiotherapy to avoid shoulder stiffness, counseling, and support.
Procedure
Complete mastectomy: Excision of the nipple/areola complex, surrounding skin, and all breast tissue
Revision of radical mastectomy:dissection of axillary lymph nodes during a mastectomy
'Halstead' or radical mastectomy:
Mastectomy (no longer practiced) with dissection of the axillary lymph nodes and excision of the pectoralis major and minor
Prolonged radical mastectomy:Internal mammary lymph node resection
Breast-sparing and breast-sparing mastectomy techniques:
preserves the surrounding skin and allows for quick restoration, although they are not appropriate for locally advanced or inflammatory tumors close to the nipple.
Access: To ensure that the wound borders can be approached, an elliptical incision encircling the lesion and nipple is made.
Elevate and meticulously dissect skin flaps, separating subcutaneous and mammary fat to prevent "button holing" in the modified radical mastectomy. Cut superiorly, medially, and inferiorly down to the breast tissue's edge. Dissect the breast tissue free of the fascia enveloping the pectoralis major. Should the tumor be attached, it must be removed using a muscular cuff. go with the lateral dissection until you reach the pectoralis major boundary. Then, go posteriorly to reach the anterior border of the lattisimus dorsi.
Axillary dissection: The axillary vessels, thoracodorsal nerve, artery to thelatissimus dorsi, and long thoracic nerve of Bell, which supplies the serratus anterior, are meticulously identified and preserved during the dissection of the axillary loose areolar tissue. The lateral axillary (level I), subscapular, central (level II), and, if required, subclavicular (level III) nodes are among those removed. Retraction or division of the pectoralis minor is used to remove these nodes up to the costoclavicular ligament.
Closure: After haemostasis is confirmed, two drains—one for the axillary and one for the mammary spaces—are implanted. Subcutaneous and skin sutures are used to approximate and close the wound, preventing "dog ears."
Reconstruction: Following a mastectomy, rapid reconstruction may be achieved by implant-based techniques, autologous tissue techniques (such as latissimus dorsi, transverse rectus abdominus, or deep inferior epigastric perforator flaps), or a combination of these techniques.
On the other hand, breast reconstruction can wait.
Complications
harm to the nerves (e.g., long thoracic nerve, trochodorsal nerve, and intercostobrachial nerve), flap necrosis, seroma, hemorrhage/haematoma, and wound infection.
Long-range: Poor cosmetic outcome, shoulder discomfort, ipsilateral arm lymphoedema, psychological issues, and tumor recurrence.
Indications
When lumpectomy alone is unable to achieve tumour-free margins, in situ carcinoma or multifocal tumours, patient preference, tumours fixed to underlying muscle, skin, or fungal with accompanying ulceration or bleeding, and bilateral prophylactic mastectomy (e.g., patients carrying the BRCA-1 or BRCA-2 genes) are among the indications for mastectomy in breast cancer cases.
Anatomy
There is a complex network of branching milk ducts that exit on the nipple (from 4 to 18 ducts; the anatomy originally reported by Cooper has been substantially changed in recent years). The breast tissue is composed of fatty and glandular tissue (ratio ranges from 1: 1 to 1: 2 in lactation). With an axillary tail, the base of the breast encloses the second through sixth ribs. Suspensory connective tissue ligaments support the breast tissue by extending from the dermis to the deep fascia.
Vascular: The internal mammary, intercostal, thoracodorsal, lateral thoracic, and thoracoacromial arteries, as well as their perforating arteries, provide the breast's arterial supply and associated venous drainage.
The lymphatic system While the medial half drains into the nodes along the internal mammary artery, the lateral half's lymphatics drain into the axillary nodes, which are made up of the anterior, posterior, lateral, central, and apical groups.
Investigations
Prior to surgery: A triple assessment of the clinical examination, imaging (mammography, ultrasound, or MRI scan), and cytology/histological analysis by FNA or trucut biopsy is used to diagnose tumors. Before a mastectomy, a biopsy should ideally confirm malignancy.
Investigation staging: CT, PET, ultrasonography, bone scans, and CXR scans can all be carried out.
Downsizing the tumor may be accomplished by neoadjuvant chemotherapy.
Blood tests: G&S, clotting, FBC, U&Es, LFT, or crossmatch. general evaluation of anesthesia.
Following surgery: bra insert fitting, DVT prophylaxis, analgesia, physiotherapy to avoid shoulder stiffness, counseling, and support.
Procedure
Complete mastectomy: Excision of the nipple/areola complex, surrounding skin, and all breast tissue
Revision of radical mastectomy:dissection of axillary lymph nodes during a mastectomy
'Halstead' or radical mastectomy:
Mastectomy (no longer practiced) with dissection of the axillary lymph nodes and excision of the pectoralis major and minor
Prolonged radical mastectomy:Internal mammary lymph node resection
Breast-sparing and breast-sparing mastectomy techniques:
preserves the surrounding skin and allows for quick restoration, although they are not appropriate for locally advanced or inflammatory tumors close to the nipple.
Access: To ensure that the wound borders can be approached, an elliptical incision encircling the lesion and nipple is made.
Elevate and meticulously dissect skin flaps, separating subcutaneous and mammary fat to prevent "button holing" in the modified radical mastectomy. Cut superiorly, medially, and inferiorly down to the breast tissue's edge. Dissect the breast tissue free of the fascia enveloping the pectoralis major. Should the tumor be attached, it must be removed using a muscular cuff. go with the lateral dissection until you reach the pectoralis major boundary. Then, go posteriorly to reach the anterior border of the lattisimus dorsi.
Axillary dissection: The axillary vessels, thoracodorsal nerve, artery to thelatissimus dorsi, and long thoracic nerve of Bell, which supplies the serratus anterior, are meticulously identified and preserved during the dissection of the axillary loose areolar tissue. The lateral axillary (level I), subscapular, central (level II), and, if required, subclavicular (level III) nodes are among those removed. Retraction or division of the pectoralis minor is used to remove these nodes up to the costoclavicular ligament.
Closure: After haemostasis is confirmed, two drains—one for the axillary and one for the mammary spaces—are implanted. Subcutaneous and skin sutures are used to approximate and close the wound, preventing "dog ears."
Reconstruction: Following a mastectomy, rapid reconstruction may be achieved by implant-based techniques, autologous tissue techniques (such as latissimus dorsi, transverse rectus abdominus, or deep inferior epigastric perforator flaps), or a combination of these techniques.
On the other hand, breast reconstruction can wait.
Complications
harm to the nerves (e.g., long thoracic nerve, trochodorsal nerve, and intercostobrachial nerve), flap necrosis, seroma, hemorrhage/haematoma, and wound infection.
Long-range: Poor cosmetic outcome, shoulder discomfort, ipsilateral arm lymphoedema, psychological issues, and tumor recurrence.
- Published on
Surgery - Bariatric Surgery
Indications
severe obesity, in which treatment with medication and lifestyle modifications has not proven successful. The following BMI ranges are recommended by NICE or NIH: more than 40 kg/m2; or 35–40 kg/m2 with comorbidities associated with obesity (such as hypertension, Type II diabetes, hyperlipidemia, and obstructive sleep apnea).
Patients must agree to long-term follow-up, undergo multidisciplinary evaluation, be suitable for anesthesia, and comprehend the implications of surgery.
Contraindications include cirrhosis, chronic pancreatitis, inflammatory bowel disease, drug or alcohol addiction, and mental disorder.
Anatomy
separated into malabsorptive, combination, and restrictive (limit intake) operations; however, the underlying mechanisms may be more intricate, such as decreased ghrelin production by the stomach fundus in sleeve gastrectomy.
Gastric restriction: Sleeve gastrectomy with laparoscopic adjustable gastric band.
Roux-en-Y gastric bypass restricts with some intestinal malabsorption.
Malabsorptive with several limitations: duodenal switch or biliopancreatic diversion.
Investigations
Pre-procedure: Dietician consultation, cardiac, endocrine, and mental evaluation, as well as a multidisciplinary workup. two weeks before surgery, a liquid diet to shrink the liver and make surgery easier Blood: iron, B12, folate, LFTs, lipids, TFT, FBC, and blood crossmatching.
Following the procedure: biliopancreatic diversion and gastric bypass Oral contrast testing to check for leaks (optional), consultation with a nutritionist, a liquid diet at first, gradually increasing, continuous vitamin and mineral supplements, monitoring, and follow-up.
Procedures
either laparoscopic or open.
Gastric band: A 15–20 ml pouch is created by wrapping an adjustable silicone band around the upper abdomen. Through a port in the subcutaneous tissue, saline inflation can be used to change the tightness of the band.
Roux-en-Y gastrojejunostomy: A 15–30 ml pouch is created by dividing the stomach in a Roux-en-Y gastric bypass, and it is linked to the jejunum.
Biliopancreatic diversion: A partial gastrectomy in which the stomach remnant is anastomosed to the distal ileum, which is the region of the ileocaecal valve where absorption takes place, between 50 and 100 cm away. By leaving the pylorus and the initial portion of the duodenum intact during the duodenal switch procedure, the risk of stomal ulcers and dumping syndrome is reduced.
Benefits: Loss of weight (gastric band: 50% extra weight can be removed, 70% for surgeries including malabsorptive procedures). decreased rates of certain cancers, diabetes, hypertension, overall mortality, increased mobility, and self-esteem are just a few of the comorbidities that can be reduced.
Many people need body contouring surgery to remove extra skin after losing weight.
Complications
Temporary: Infection, bleeding, anastomotic leaks, PE/DVT, arrhythmias, and 30-day mortality less than 1% are considered general.
Particulars: erosion, migration, and gastroband slippage.Symptoms of gastric reflux include overeating-related nausea and vomiting, ulcers, internal herniation, anddumping syndrome.
Long-range: Anastomotic stenosis, marginal ulceration, internal herniation, gallstones, malabsorption, neurological symptoms, bone demineralization, protein-calorie malnutrition, failure (of weight loss or weight regain, 5–10%), and nutritional deficiencies, such as those involving iron, calcium, fat-soluble vitamins, thiamine, B12, and copper
Indications
severe obesity, in which treatment with medication and lifestyle modifications has not proven successful. The following BMI ranges are recommended by NICE or NIH: more than 40 kg/m2; or 35–40 kg/m2 with comorbidities associated with obesity (such as hypertension, Type II diabetes, hyperlipidemia, and obstructive sleep apnea).
Patients must agree to long-term follow-up, undergo multidisciplinary evaluation, be suitable for anesthesia, and comprehend the implications of surgery.
Contraindications include cirrhosis, chronic pancreatitis, inflammatory bowel disease, drug or alcohol addiction, and mental disorder.
Anatomy
separated into malabsorptive, combination, and restrictive (limit intake) operations; however, the underlying mechanisms may be more intricate, such as decreased ghrelin production by the stomach fundus in sleeve gastrectomy.
Gastric restriction: Sleeve gastrectomy with laparoscopic adjustable gastric band.
Roux-en-Y gastric bypass restricts with some intestinal malabsorption.
Malabsorptive with several limitations: duodenal switch or biliopancreatic diversion.
Investigations
Pre-procedure: Dietician consultation, cardiac, endocrine, and mental evaluation, as well as a multidisciplinary workup. two weeks before surgery, a liquid diet to shrink the liver and make surgery easier Blood: iron, B12, folate, LFTs, lipids, TFT, FBC, and blood crossmatching.
Following the procedure: biliopancreatic diversion and gastric bypass Oral contrast testing to check for leaks (optional), consultation with a nutritionist, a liquid diet at first, gradually increasing, continuous vitamin and mineral supplements, monitoring, and follow-up.
Procedures
either laparoscopic or open.
Gastric band: A 15–20 ml pouch is created by wrapping an adjustable silicone band around the upper abdomen. Through a port in the subcutaneous tissue, saline inflation can be used to change the tightness of the band.
Roux-en-Y gastrojejunostomy: A 15–30 ml pouch is created by dividing the stomach in a Roux-en-Y gastric bypass, and it is linked to the jejunum.
Biliopancreatic diversion: A partial gastrectomy in which the stomach remnant is anastomosed to the distal ileum, which is the region of the ileocaecal valve where absorption takes place, between 50 and 100 cm away. By leaving the pylorus and the initial portion of the duodenum intact during the duodenal switch procedure, the risk of stomal ulcers and dumping syndrome is reduced.
Benefits: Loss of weight (gastric band: 50% extra weight can be removed, 70% for surgeries including malabsorptive procedures). decreased rates of certain cancers, diabetes, hypertension, overall mortality, increased mobility, and self-esteem are just a few of the comorbidities that can be reduced.
Many people need body contouring surgery to remove extra skin after losing weight.
Complications
Temporary: Infection, bleeding, anastomotic leaks, PE/DVT, arrhythmias, and 30-day mortality less than 1% are considered general.
Particulars: erosion, migration, and gastroband slippage.Symptoms of gastric reflux include overeating-related nausea and vomiting, ulcers, internal herniation, anddumping syndrome.
Long-range: Anastomotic stenosis, marginal ulceration, internal herniation, gallstones, malabsorption, neurological symptoms, bone demineralization, protein-calorie malnutrition, failure (of weight loss or weight regain, 5–10%), and nutritional deficiencies, such as those involving iron, calcium, fat-soluble vitamins, thiamine, B12, and copper
- Published on
Surgery - Cardiac Transplantation
Indications
99% of cases are of ischemic heart disease and idiopathic cardiomyopathy.
Myocarditis (1%), valvular heart disease, and congenital heart disease.
Qualifications for recipients:. end-stage heart disease with less than a year to live.
lack of renal or hepatic dysfunction.
lack of a tumor or active systemic infection.
psychosocial stability and the capacity to adhere to immunosuppressive treatment and aftercare.
Anatomy
Orthotopic transplantation: The majority of the recipient's heart is replaced by the donor heart. The ventricles are removed from the latter, leaving the large vessels—the right and left atriums—in place.
The left atria, followed by the right atria, and finally the large vessels, are anastomosed to the donor heart.
As an alternative, bicaval anastamosis (which reduces atrial and valvular issues) can be carried out.
Heterotopic transplantation involves positioning the donor heart parallel to the recipient's heart without removing the recipient's heart. less frequently carried out. The recipient's heart is aided by the donor heart. is feasible when pulmonary hypertension is present.
Investigations
Prior to surgery: comprehensive interdisciplinary workup that includes tissue typing, panel-reactive antibodies, blood testing, blood grouping, and infection screening. Anaesthetic evaluation.
Imaging: CXR, echo, and coronary angiography. testing for pulmonary function. Evaluation of maximal venous oxygen consumption (MVO2), a measure of the severity of heart failure, and pulmonary vascular resistance.
Donors: Heart beating and brain stem death requirements met in an ABO compatible manner. must not have any heart pathologies. A team of experts performs donor surgery. The heart can only withstand brief preservation periods—up to six hours.
After surgery, patients are first closely monitored in intensive care.
Immunosuppressive medication is administered, such as azathioprine or cyclosporin. Biopsies of the endomyocardium are performed to evaluate for graft rejection.
Procedure (Orthotopic )
Entry: Sternotomy median.
Cardiopulmonary bypass: Used during cardiac surgery to oxygenate and circulate blood.
Removal of recipient organ: A mid-atrial incision is performed across the recipient's left and right atria. Just prior to the left and right pulmonary arteries splitting off, the ascending aorta and the pulmonary artery split. The heart of the recipient is extracted.
Preparing a donor organ: The heart is meticulously ready for implantation.
Recipient transplantation (inflow anastomosis): Running sutures are used to anastomose the left atrium to the recipient's remaining left atria. To keep the donor heart cool, topical cooling with frozen saline slush is given externally.
After that, the recipient's remaining right atrium is anastomosed to the right atrium.
reestablishing outflow anastomosis and circulation: As the pulmonary artery and aorta are being anastomosed, systemic rewarming is initiated. Either spontaneously or with cardioversion, sinus rhythm recovers. The bypass circuit is progressively turned off for the patient, enabling the heart to fill and start the cardiac ejection process again. All cannulas are withdrawn once cardiac output is deemed sufficient.
Closure: Two thoracostomy drains are placed in the chest cavity and pericardium, and temporary pacing wires are implanted into the atrium and/or ventricles. The skin is closed and the sternum is sealed with broken steel wires.
Complications
Early symptoms include hemorrhage, infection, organ failure, severe rejection, and arrhythmias.
Late: Hypertension, chronic rejection, infection, valve regurgitation, accelerated coronary artery disease, and post-transplantation malignancy.
Prognosis
3-5% is the operational mortality rate. 90% of people survive one year, and 78% survive five.
Indications
99% of cases are of ischemic heart disease and idiopathic cardiomyopathy.
Myocarditis (1%), valvular heart disease, and congenital heart disease.
Qualifications for recipients:. end-stage heart disease with less than a year to live.
lack of renal or hepatic dysfunction.
lack of a tumor or active systemic infection.
psychosocial stability and the capacity to adhere to immunosuppressive treatment and aftercare.
Anatomy
Orthotopic transplantation: The majority of the recipient's heart is replaced by the donor heart. The ventricles are removed from the latter, leaving the large vessels—the right and left atriums—in place.
The left atria, followed by the right atria, and finally the large vessels, are anastomosed to the donor heart.
As an alternative, bicaval anastamosis (which reduces atrial and valvular issues) can be carried out.
Heterotopic transplantation involves positioning the donor heart parallel to the recipient's heart without removing the recipient's heart. less frequently carried out. The recipient's heart is aided by the donor heart. is feasible when pulmonary hypertension is present.
Investigations
Prior to surgery: comprehensive interdisciplinary workup that includes tissue typing, panel-reactive antibodies, blood testing, blood grouping, and infection screening. Anaesthetic evaluation.
Imaging: CXR, echo, and coronary angiography. testing for pulmonary function. Evaluation of maximal venous oxygen consumption (MVO2), a measure of the severity of heart failure, and pulmonary vascular resistance.
Donors: Heart beating and brain stem death requirements met in an ABO compatible manner. must not have any heart pathologies. A team of experts performs donor surgery. The heart can only withstand brief preservation periods—up to six hours.
After surgery, patients are first closely monitored in intensive care.
Immunosuppressive medication is administered, such as azathioprine or cyclosporin. Biopsies of the endomyocardium are performed to evaluate for graft rejection.
Procedure (Orthotopic )
Entry: Sternotomy median.
Cardiopulmonary bypass: Used during cardiac surgery to oxygenate and circulate blood.
Removal of recipient organ: A mid-atrial incision is performed across the recipient's left and right atria. Just prior to the left and right pulmonary arteries splitting off, the ascending aorta and the pulmonary artery split. The heart of the recipient is extracted.
Preparing a donor organ: The heart is meticulously ready for implantation.
Recipient transplantation (inflow anastomosis): Running sutures are used to anastomose the left atrium to the recipient's remaining left atria. To keep the donor heart cool, topical cooling with frozen saline slush is given externally.
After that, the recipient's remaining right atrium is anastomosed to the right atrium.
reestablishing outflow anastomosis and circulation: As the pulmonary artery and aorta are being anastomosed, systemic rewarming is initiated. Either spontaneously or with cardioversion, sinus rhythm recovers. The bypass circuit is progressively turned off for the patient, enabling the heart to fill and start the cardiac ejection process again. All cannulas are withdrawn once cardiac output is deemed sufficient.
Closure: Two thoracostomy drains are placed in the chest cavity and pericardium, and temporary pacing wires are implanted into the atrium and/or ventricles. The skin is closed and the sternum is sealed with broken steel wires.
Complications
Early symptoms include hemorrhage, infection, organ failure, severe rejection, and arrhythmias.
Late: Hypertension, chronic rejection, infection, valve regurgitation, accelerated coronary artery disease, and post-transplantation malignancy.
Prognosis
3-5% is the operational mortality rate. 90% of people survive one year, and 78% survive five.
- Published on
Surgery - Carotid Endarterectomy
Indications
More than 70–99% symptomatic carotid stenosis (Absolute).
(Relative) Symptomatic stenosis >50%, ideally within two weeks of the patient's last symptoms, if the perioperative stroke/death rate is <6%.
(Relative) Asymptomatic men under 75 years old with 70–99% stenosis, if there is less than 3% chance of stroke or death after surgery.
Anatomy
The left common carotid artery originates from the aortic arch, while the right common carotid arises at the innominate artery's bifurcation behind the right sternoclavicular joint. The external carotid, which supplies the outside skull, face, and most of the neck, and the internal carotid, which has no branches in the neck, split the common carotid (level can vary, C4). A number of nerves are at risk during carotid dissection: (1) the mandibular branch of the facial nerve; (2) the hypoglossal nerve courses medially across the anterior aspect of the external and internal carotids to supply the tongue; and (3) the vagus nerve exits the jugular foramen and courses caudally in the carotid sheath, putting its superior and recurrent laryngeal branches at risk. The carotids are located next to the internal jugular vein.
Investigations
Prior to surgery: The carotid duplex is the initial test used to measure the degree of stenosis. Digital subtraction angiography and CT and MR angiography are other imaging modalities. As concomitant coronary artery disease is frequently present, a coronary angiography, echocardiography, and ECG are recommended. Aspirin and statins ought to be administered prior to, during, and after surgery.
Post-operative care should include regular neurologic evaluation, hemodynamic testing, and electrocardiogram monitoring. Keep an eye out for any bleeding that could endanger the airway.
Aftercare: Controlling cardiovascular risk factors. A carotid duplex can be used to check for contralateral stenosis or restenosis at different intervals.
Procedure
Anaesthesia: Both local and general anesthesia are safe for use (GALA trial). The benefit of the latter is that it does not require sophisticated monitoring and allows for a direct assessment of the patient's neurological condition. Under GA, transcranial Doppler, stump pressures, and EEG can all be used to measure cerebral blood flow.
Incision: The anterior border of the sternocleidomastoid muscle is incised obliquely. Carotid bifurcation localization or preoperative labeling can be useful.
The common, internal, and exterior carotid arteries are dissected: vascular manipulation and dissection done carefully to prevent embolism. preventing damage to the hypoglossal and vagus nerves, as well as the internal jugular vein and its tributaries. Changes in blood pressure can be caused via carotid body manipulation.
A longitudinal arteriotomy is done from the common into the internal carotid after the arteries are constricted after heparinization. A shunt is installed if necessary, such as the Pruitt-Inahara or Javid shunts.
Plaque removal: Using a suitable tool, such as a Watson Cheyne dissector, the plaque is pulled away from the arterial wall, being careful not to cause intimal flaps. Debris and clots are then flushed out with heparinized saline.
Closure: If a shunt was inserted, it is removed and the arteriotomy is sealed using prolene suture. A prosthesis or vein patch can be used to close the arteriotomy directly.Adrain is frequently left in place till the next day.
Complications
cardiac ischaemia, hemorrhage, hypertension, hypotension, perioperative stroke, and nerve injury (2–7%, mandibular branch of the facial nerve, recurrent laryngeal nerve, or hypoglossal nerves). 1.8% to 0.5% is the perioperative mortality rate.
Indications
More than 70–99% symptomatic carotid stenosis (Absolute).
(Relative) Symptomatic stenosis >50%, ideally within two weeks of the patient's last symptoms, if the perioperative stroke/death rate is <6%.
(Relative) Asymptomatic men under 75 years old with 70–99% stenosis, if there is less than 3% chance of stroke or death after surgery.
Anatomy
The left common carotid artery originates from the aortic arch, while the right common carotid arises at the innominate artery's bifurcation behind the right sternoclavicular joint. The external carotid, which supplies the outside skull, face, and most of the neck, and the internal carotid, which has no branches in the neck, split the common carotid (level can vary, C4). A number of nerves are at risk during carotid dissection: (1) the mandibular branch of the facial nerve; (2) the hypoglossal nerve courses medially across the anterior aspect of the external and internal carotids to supply the tongue; and (3) the vagus nerve exits the jugular foramen and courses caudally in the carotid sheath, putting its superior and recurrent laryngeal branches at risk. The carotids are located next to the internal jugular vein.
Investigations
Prior to surgery: The carotid duplex is the initial test used to measure the degree of stenosis. Digital subtraction angiography and CT and MR angiography are other imaging modalities. As concomitant coronary artery disease is frequently present, a coronary angiography, echocardiography, and ECG are recommended. Aspirin and statins ought to be administered prior to, during, and after surgery.
Post-operative care should include regular neurologic evaluation, hemodynamic testing, and electrocardiogram monitoring. Keep an eye out for any bleeding that could endanger the airway.
Aftercare: Controlling cardiovascular risk factors. A carotid duplex can be used to check for contralateral stenosis or restenosis at different intervals.
Procedure
Anaesthesia: Both local and general anesthesia are safe for use (GALA trial). The benefit of the latter is that it does not require sophisticated monitoring and allows for a direct assessment of the patient's neurological condition. Under GA, transcranial Doppler, stump pressures, and EEG can all be used to measure cerebral blood flow.
Incision: The anterior border of the sternocleidomastoid muscle is incised obliquely. Carotid bifurcation localization or preoperative labeling can be useful.
The common, internal, and exterior carotid arteries are dissected: vascular manipulation and dissection done carefully to prevent embolism. preventing damage to the hypoglossal and vagus nerves, as well as the internal jugular vein and its tributaries. Changes in blood pressure can be caused via carotid body manipulation.
A longitudinal arteriotomy is done from the common into the internal carotid after the arteries are constricted after heparinization. A shunt is installed if necessary, such as the Pruitt-Inahara or Javid shunts.
Plaque removal: Using a suitable tool, such as a Watson Cheyne dissector, the plaque is pulled away from the arterial wall, being careful not to cause intimal flaps. Debris and clots are then flushed out with heparinized saline.
Closure: If a shunt was inserted, it is removed and the arteriotomy is sealed using prolene suture. A prosthesis or vein patch can be used to close the arteriotomy directly.Adrain is frequently left in place till the next day.
Complications
cardiac ischaemia, hemorrhage, hypertension, hypotension, perioperative stroke, and nerve injury (2–7%, mandibular branch of the facial nerve, recurrent laryngeal nerve, or hypoglossal nerves). 1.8% to 0.5% is the perioperative mortality rate.
