- Published on
Surgery - Chest Drain
Indication
Pneumothorax: Consistent or recurrent after simple aspiration; trauma; tension during needle decompression; ventilated patients.
Trauma in a hemothorax.
Pleural effusions, such as parapneumonic and malignant ones.
Postoperative: after, as in thoracotomy, oesophagectomy, and heart surgery.
Anatomy
The "safe triangle," which is formed by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, the apex below the axilla, and the upper border of the sixth rib, is where the chest drain insertion should be located. The diaphragm rises to the fifth rib upon expiration, hence placement should occur in the fourth or fifth rib gap. To prevent damage to the intercosal nerve and vascular bundles that run beneath each rib, the superior portion of the rib should be covered by the dissection and drain location.
Investigations
Tension pneumothorax: None is required; immediately do emergency decompression using a large-bore cannula in the midclavicular line's second intercostal gap.
Prior to procedure: Imaging: CXR, sometimes CT, depending on the situation being treated. In cases of effusions or empyemas, ultrasoundguided drain insertion can be helpful in guiding safe placement.
oxygen, analgesia, informed consent and explanation, and coagulopathy repair.
Post-procedure: To determine tube location, repeat CXR. close observation of production, bubbling, and swinging.
Actions
Positioning: To provide access to the sidewall of the chest, position the patient, for example, by reclining back with their arm abducted. Verify the right side. Clean the skin using aseptic approach, then drape.
Make an incision and inject a local anesthetic. Make an incision at the fourth or fifth intercostal space, usually just anterior to the midaxillary line. In order to prevent the neurovascular bundle from entering the chest through the pleura with a palpable "pop," bluntly dissect through the intercostal muscles above the fifth or sixth rib.
Insertion: If required, insert a chest drain (32–36F in trauma) fixed on a clamp and enter a finger to make sure there are no adhesions. Drainage is directed apically for pneumothorax and basally for fluid.
Securing the drain: To close the wound after the drain is withdrawn, a non-absorbable stitch and a loosely placed purse string should be used to hold the drain in place. An underwater seal is where the drain is fastened.
Care for chest drains: It is almost never advisable to clamp chest drains because this can cause a tension pneumthorax. The patient should never have the drain bottle raised above them, since this could cause fluid to spill into them. With every breath, the meniscus in the bottle ought to "swing."
Complications
harm to the upper abdominal, mediastinal, and thoracic tissues. The following conditions can occur: lung laceration, diaphragmatic injury, empyema and infection, blocked drain, recurrence after removal, and hemothorax (frequently an intercostal artery injury that may necessitate a thoracotomy).
Indication
Pneumothorax: Consistent or recurrent after simple aspiration; trauma; tension during needle decompression; ventilated patients.
Trauma in a hemothorax.
Pleural effusions, such as parapneumonic and malignant ones.
Postoperative: after, as in thoracotomy, oesophagectomy, and heart surgery.
Anatomy
The "safe triangle," which is formed by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, the apex below the axilla, and the upper border of the sixth rib, is where the chest drain insertion should be located. The diaphragm rises to the fifth rib upon expiration, hence placement should occur in the fourth or fifth rib gap. To prevent damage to the intercosal nerve and vascular bundles that run beneath each rib, the superior portion of the rib should be covered by the dissection and drain location.
Investigations
Tension pneumothorax: None is required; immediately do emergency decompression using a large-bore cannula in the midclavicular line's second intercostal gap.
Prior to procedure: Imaging: CXR, sometimes CT, depending on the situation being treated. In cases of effusions or empyemas, ultrasoundguided drain insertion can be helpful in guiding safe placement.
oxygen, analgesia, informed consent and explanation, and coagulopathy repair.
Post-procedure: To determine tube location, repeat CXR. close observation of production, bubbling, and swinging.
Actions
Positioning: To provide access to the sidewall of the chest, position the patient, for example, by reclining back with their arm abducted. Verify the right side. Clean the skin using aseptic approach, then drape.
Make an incision and inject a local anesthetic. Make an incision at the fourth or fifth intercostal space, usually just anterior to the midaxillary line. In order to prevent the neurovascular bundle from entering the chest through the pleura with a palpable "pop," bluntly dissect through the intercostal muscles above the fifth or sixth rib.
Insertion: If required, insert a chest drain (32–36F in trauma) fixed on a clamp and enter a finger to make sure there are no adhesions. Drainage is directed apically for pneumothorax and basally for fluid.
Securing the drain: To close the wound after the drain is withdrawn, a non-absorbable stitch and a loosely placed purse string should be used to hold the drain in place. An underwater seal is where the drain is fastened.
Care for chest drains: It is almost never advisable to clamp chest drains because this can cause a tension pneumthorax. The patient should never have the drain bottle raised above them, since this could cause fluid to spill into them. With every breath, the meniscus in the bottle ought to "swing."
Complications
harm to the upper abdominal, mediastinal, and thoracic tissues. The following conditions can occur: lung laceration, diaphragmatic injury, empyema and infection, blocked drain, recurrence after removal, and hemothorax (frequently an intercostal artery injury that may necessitate a thoracotomy).
- Published on
Surgery - Cholecystectomy
Indications
Symptomatic gallstones.
can be performed in an acute situation, that is, on a gallbladder that is "hot," within 72 hours of the commencement of acute cholecystitis.
For cholecystectomy that is open: suspected malignancy of the gallbladder.
Switching from laparoscopic to Incapacity to recognize anatomy, such as several adhesions, stagnation, or postoperative problems.
Anatomy
The fundus, body, infundibulum, and neck—which has the potential to produce a Hartmann's pouch—compose the gallbladder. The mucosa of the cystic duct, which joins the gallbladder to the confluence of the common bile and hepatic ducts, produces spiral valves of Heister folds. Variations in anatomy are frequent. Calot's triangle, which is composed of the liver's inferior border, the common hepatic duct medially, and the cystic duct inferiorly, is crucial to dissection. Usually passing through here and leading to the gallbladder is the cystic artery, a branch of the right hepatic artery.
It is possible for a Luschka duct to go straight between the gallbladder and the liver.
Investigations
Preoperative ultrasound for gallstone diagnosis. The baseline blood tests are FBC, U&Es, LFTs, and G&S.
Post-operative: A day case procedure for laparoscopic cholecystectomy is possible. DVT prevention.
Procedure
Anesthesia: anesthesia generale. prophylactic antibiotic use in case of bile leakage.
Operation:
Laparoscopy: Either a closed (Veress needle) or an open (Hassan) approach is used to introduce the primary trocar. Insufflation of CO2 produces a pneumoperitoneum. Following examination, three more ports are inserted under direct vision: two along the right costal margin and one epigastric port. The stomach can be made smaller with the use of a nasogastric tube.
The head of the patient is cocked to the right.
Open: A Kocher's (right subcostal) incision is made.
Cholecystectomy: Calot's triangle is shown by grasping and retracting the gallbladder upward. Vigilance is required for anatomical variation. Omental and peritoneal adhesions are split, and dissection is undertaken to find the cystic duct and cystic artery.
If necessary, an intraoperative cholangiogram can be carried out to detect stones in the common bile duct after the cystic duct is severed close to the gallbladder. The cystic artery and duct are split and clipped both distally and proximally. Next, the gallbladder is removed from the liver's subsurface. Gallstones that have spilled should be found and removed. If bleeding or bile leakage is a concern, a subhepatic drain may be implanted.
Closure: A bag containing the gallbladder is used. After local lavage if required and hemostasis, the bag is removed using a port site. The incisions are closed and the ports are taken out under direct vision.
Complications
Early: bleeding, visceral injury, infection, bile leak, bile duct injury (risk enhanced in the presence of active inflammation).
Extensive dyspeptic symptoms following cholecystectomy, biliary stricture, portsite or incisional hernias are examples of late complications.
Indications
Symptomatic gallstones.
can be performed in an acute situation, that is, on a gallbladder that is "hot," within 72 hours of the commencement of acute cholecystitis.
For cholecystectomy that is open: suspected malignancy of the gallbladder.
Switching from laparoscopic to Incapacity to recognize anatomy, such as several adhesions, stagnation, or postoperative problems.
Anatomy
The fundus, body, infundibulum, and neck—which has the potential to produce a Hartmann's pouch—compose the gallbladder. The mucosa of the cystic duct, which joins the gallbladder to the confluence of the common bile and hepatic ducts, produces spiral valves of Heister folds. Variations in anatomy are frequent. Calot's triangle, which is composed of the liver's inferior border, the common hepatic duct medially, and the cystic duct inferiorly, is crucial to dissection. Usually passing through here and leading to the gallbladder is the cystic artery, a branch of the right hepatic artery.
It is possible for a Luschka duct to go straight between the gallbladder and the liver.
Investigations
Preoperative ultrasound for gallstone diagnosis. The baseline blood tests are FBC, U&Es, LFTs, and G&S.
Post-operative: A day case procedure for laparoscopic cholecystectomy is possible. DVT prevention.
Procedure
Anesthesia: anesthesia generale. prophylactic antibiotic use in case of bile leakage.
Operation:
Laparoscopy: Either a closed (Veress needle) or an open (Hassan) approach is used to introduce the primary trocar. Insufflation of CO2 produces a pneumoperitoneum. Following examination, three more ports are inserted under direct vision: two along the right costal margin and one epigastric port. The stomach can be made smaller with the use of a nasogastric tube.
The head of the patient is cocked to the right.
Open: A Kocher's (right subcostal) incision is made.
Cholecystectomy: Calot's triangle is shown by grasping and retracting the gallbladder upward. Vigilance is required for anatomical variation. Omental and peritoneal adhesions are split, and dissection is undertaken to find the cystic duct and cystic artery.
If necessary, an intraoperative cholangiogram can be carried out to detect stones in the common bile duct after the cystic duct is severed close to the gallbladder. The cystic artery and duct are split and clipped both distally and proximally. Next, the gallbladder is removed from the liver's subsurface. Gallstones that have spilled should be found and removed. If bleeding or bile leakage is a concern, a subhepatic drain may be implanted.
Closure: A bag containing the gallbladder is used. After local lavage if required and hemostasis, the bag is removed using a port site. The incisions are closed and the ports are taken out under direct vision.
Complications
Early: bleeding, visceral injury, infection, bile leak, bile duct injury (risk enhanced in the presence of active inflammation).
Extensive dyspeptic symptoms following cholecystectomy, biliary stricture, portsite or incisional hernias are examples of late complications.
- Published on
Surgery - Male Circumcision
Indications
Elective: Usually carried out in infants or young boys due to cultural or religious reasons.
Penile cancer, phimosis, paraphimosis, recurrent balanoposthitis (infection of the penis and foreskin), and balanitis xerotica obliterans (lichen sclerosus of the foreskin) are among the conditions that might occur.
Hypopadias, chordee, and hidden penis are contraindications.
Emergency: Severe inflammation/infection of the penis or foreskin; in these situations, a dorsal slit of the phimotic foreskin is more secure because there's a chance of worsening the infection and achieving subpar cosmesis. Following the resolution of the infection and swelling, a formal circumcision is carried out.
Anatomy
The external urethral meatus and glans are covered and shielded by the foreskin. It is made up of layers of dartos muscle and the lamina propria underneath the stratified squamous epithelium.
Boys gradually separate from the glans, and 90% of them have done so by the time they are 5 years old.
Vascular supply: The penile skin is supplied by the superficial branches of the external pudendal arteries and the dorsal artery from the internal pudendal artery. The superficial dorsal vein empties into the superficial external pudendal vein, which is the route of venous drainage.
Nerve supply: The dorsal nerve of the penis, a branch of the pudendal nerve, and the perineal nerves from S2, S3, and S4 innervate the area.
Investigational studies
No specific pre-operative investigations are required if the patient is in good health.
Action
can be carried out as a day procedure with either a local or caudal penile block or general anesthesia.
Method: The most popular method entails cutting a dorsal incision, carefully maintaining hemostasis, and then removing the foreskin. Broken absorbable sutures are used to join the penile skin to mucosa at the corona. To stop underwear from sticking to the incision, a gauze dressing is applied. It is standard procedure to send the foreskin for histological analysis.
An alternate method of circumcision called "forceps-guided" involves pulling the foreskin forward in front of the glans, clamping a forceps over it, and then excising it with a knife. After that, the inner and outer skin's sliced edges are sewn together.
Plastibel circumcision: The foreskin is introduced by dorsally cutting it, and a plastic ring is positioned underneath. After the ring is covered with a ligature, the distal tissue necroses. After a week or two, the dead foreskin and ring fall off.
Complications
Early symptoms include infection, urine retention, penile damage (such as diathermy burns), and bleeding (1%–2%).
Late: Stitches sinus, urethral fistula, chordee from excessive skin removal, recurring phimosis from inadequate circumcision, and meatal stenosis or ulcer.
Prognosis
a routine operation that is typically carried out for benign issues or cultural reasons.
Indications
Elective: Usually carried out in infants or young boys due to cultural or religious reasons.
Penile cancer, phimosis, paraphimosis, recurrent balanoposthitis (infection of the penis and foreskin), and balanitis xerotica obliterans (lichen sclerosus of the foreskin) are among the conditions that might occur.
Hypopadias, chordee, and hidden penis are contraindications.
Emergency: Severe inflammation/infection of the penis or foreskin; in these situations, a dorsal slit of the phimotic foreskin is more secure because there's a chance of worsening the infection and achieving subpar cosmesis. Following the resolution of the infection and swelling, a formal circumcision is carried out.
Anatomy
The external urethral meatus and glans are covered and shielded by the foreskin. It is made up of layers of dartos muscle and the lamina propria underneath the stratified squamous epithelium.
Boys gradually separate from the glans, and 90% of them have done so by the time they are 5 years old.
Vascular supply: The penile skin is supplied by the superficial branches of the external pudendal arteries and the dorsal artery from the internal pudendal artery. The superficial dorsal vein empties into the superficial external pudendal vein, which is the route of venous drainage.
Nerve supply: The dorsal nerve of the penis, a branch of the pudendal nerve, and the perineal nerves from S2, S3, and S4 innervate the area.
Investigational studies
No specific pre-operative investigations are required if the patient is in good health.
Action
can be carried out as a day procedure with either a local or caudal penile block or general anesthesia.
Method: The most popular method entails cutting a dorsal incision, carefully maintaining hemostasis, and then removing the foreskin. Broken absorbable sutures are used to join the penile skin to mucosa at the corona. To stop underwear from sticking to the incision, a gauze dressing is applied. It is standard procedure to send the foreskin for histological analysis.
An alternate method of circumcision called "forceps-guided" involves pulling the foreskin forward in front of the glans, clamping a forceps over it, and then excising it with a knife. After that, the inner and outer skin's sliced edges are sewn together.
Plastibel circumcision: The foreskin is introduced by dorsally cutting it, and a plastic ring is positioned underneath. After the ring is covered with a ligature, the distal tissue necroses. After a week or two, the dead foreskin and ring fall off.
Complications
Early symptoms include infection, urine retention, penile damage (such as diathermy burns), and bleeding (1%–2%).
Late: Stitches sinus, urethral fistula, chordee from excessive skin removal, recurring phimosis from inadequate circumcision, and meatal stenosis or ulcer.
Prognosis
a routine operation that is typically carried out for benign issues or cultural reasons.
- Published on
Surgery - Colorectal Resections, Abdomio Perineal Resection
Indications
lower rectum tumors that remain after chemotherapy and radiation therapy because they are too near the anal sphincter to get sufficient margins.
Anatomy
Starting at the level of the third sacral vertebra, the rectum (12 cm) extends anteriorly to the tip of the coccyx before descending and lying in the sacrococcygeal curve. Then, it makes a dramatic backward turn into the anal canal. The mesorectum is separated from the sacrum and hypogastric nerves posteriorly by the endopelvic (Waldeyer's) fascia, which is anteriorly located in the fascia of Denonvilliers, bladder, prostate, or vagina.
Vascular: The superior rectal artery receives blood from the inferior mesenteric artery to supply the upper rectum. The internal iliac artery is the source of the middle and inferior rectal arteries, which supply the lower rectum. The superior, middle, and inferior rectal vessels receive drainage from the rectal venous plexus. The portacaval connection is located in the rectal venous plexus.
Lymphatics: The anus below the dentate line drains to inguinal nodes, the lower can flow to internal iliac nodes, and the lymph from the upper and middle rectum drains to inferior mesenteric nodes.
Investigations
Imaging: CT, MRI, endorectal ultrasound: Used to plan and determine whether an abdominoperineal excision is appropriate.
Colonoscopy: To diagnose tissue and rule out concurrent tumors.
Blood tests, electrocardiograms, thromboprophylaxis, stoma marking, general anesthesia evaluation, and bowel preparation are all done prior to surgery.
Enhanced recovery following elective surgery includes an early return to eating and drinking, mobilization, effective analgesia, IV fluids until oral intake is sufficient, and monitoring of the whole blood count, electrolyte levels, and urine output. Maintain wound and stoma care, thromboprophylaxis, and education.
Procedure
The patient is positioned in the Lloyd Davies manner. The anal orifice is closed with sutures.
Lower midline incision, or laparoscopic procedures are also an option.
Mobilization: Similar to a low anterior resection, the left colon and sigmoid are mobilized. There is a division in the inferior mesenteric vein and artery. The rectum is dissected and mobilized, and the entire mesorectal region is removed down to the levator ani muscles. During the perineal phase, the anoccygeal ligament is divided posteriorly by making an oval incision around the anus. After this, the incision is made deeper into the muscle till it connects to the surgical site on the abdomen.
The anus and rectum are removed from the perineal side after colon division. It is customary to create an end colostomy in the left iliac fossa.
Closure: An in situ pelvic drain may be used. Subcuticular sutures are used to close the perineal surface and there is a mass closure of the abdominal wall using clips or sutures to skin.
Complications
Bleeding, infection, stoma necrosis or perineal wound necrosis, ileus, bladder dysfunction or impotence as a result of nerve injury, hernia, DVT/PE, and recurrence.
- Published on
Surgery - Colorectal Resection, Left Hemicolectomy
Indications
Elective: The most typical indications include tumors of the proximal sigmoid colon and descending colon. extreme diverticular illness.
Emergency: In rare cases, recommended for ischaemia, hemorrhage, perforation, or blockage.
Anatomy
The peritoneum covers the anterior surface and sides of the descending colon, which extends from the splenic flexure to the sigmoid colon at the pelvic brim. The phrenicocolic ligament, which runs parallel to the larger omentum and is closely linked to the spleen and tail of the pancreas, connects the splenic flexure to the diaphragm. Associated with the left kidney, lumbar region, and iliac fascia posteriorly.
vascular The sigmoid colon, the superior two thirds of the rectum, and the descending colon are all supplied by the inferior mesenteric artery (IMA). The IMA gives rise to the left colic artery, and the marginal artery (of Drummond) is partially formed by its ascending branch. The portal system receives venous drainage from the inferior mesenteric vein.
Investigations
Imaging: CT scan for staging and diagnosis; barium enema; erect CXR; abdominal radiograph.
Colonoscopy and sigmoidoscopy: For biopsy and diagnosis. Colonic lesion extraluminal localization can be facilitated by endoscopic tattooing.
Bloods: FBC, U&Es, clotting, and crossmatch prior to surgery. general evaluation of anesthesia. dosage of thromboprophylaxis, a preventive antibiotic. Preparing the bowels may be necessary.
After surgery: Better recuperation, prompt resumption of food and drink, mobilization, and effective analgesia. IV fluids are continued until oral intake is sufficient. Maintaining a precise record of fluid equilibrium is necessary. prevention of DVT. Revert to an NG tube and IV fluids until symptoms of post-operative ileus subside. In the postoperative phase, if there are any indications of a systemic disturbance, an anastomotic leak must be ruled out.
Procedure
Position: Lloyd Davis/modified lithotomy.
Access: Laparoscopic or midline incision methods. The contents of the abdomen are examined, looking for signs of liver metastases or swollen lymph nodes, and the small bowel is packed away from the left hemicolon.
The division of the peritoneal attachments at the white line of Toldt to the level of the splenic flexure mobilizes the descending colon. The spleen, left ureter, gonadal arteries, kidney, pancreas, and fourth portion of the duodenum must all be carefully avoided. Enough transverse colon mobilization occurs to allow for a tension-free anastomosis.
Ligation of vessels: The inferior mesentery artery and left colonic branches are located by dissecting the mesentery. The artery supply to the proximal and distal edges is then preserved by isolating, ligating, and dividing them.
Resection of bowel segment: The colonic segment and its accompanying mesentery are removed, and the bowel is clamped and separated, usually using linear staples.
Restoring intestinal continuity involves performing a handsewn or stapled anastomosis between the descending colon and the rectosigmoid colon. Closing the mesenteric defect prevents internal herniation.It is possible to create an aproximal defuncting stoma to shield the distal anastomosis.
Conclusion: Hemostasis is verified. Usually, a drain is installed. Sutures or clips are used to finish the skin closure once the abdominal wall is mass closed.
Complications
bleeding, infection, ileus, anastomotic leak, hernias, and thromboembolism are examples of visceral injuries.
Indications
Elective: The most typical indications include tumors of the proximal sigmoid colon and descending colon. extreme diverticular illness.
Emergency: In rare cases, recommended for ischaemia, hemorrhage, perforation, or blockage.
Anatomy
The peritoneum covers the anterior surface and sides of the descending colon, which extends from the splenic flexure to the sigmoid colon at the pelvic brim. The phrenicocolic ligament, which runs parallel to the larger omentum and is closely linked to the spleen and tail of the pancreas, connects the splenic flexure to the diaphragm. Associated with the left kidney, lumbar region, and iliac fascia posteriorly.
vascular The sigmoid colon, the superior two thirds of the rectum, and the descending colon are all supplied by the inferior mesenteric artery (IMA). The IMA gives rise to the left colic artery, and the marginal artery (of Drummond) is partially formed by its ascending branch. The portal system receives venous drainage from the inferior mesenteric vein.
Investigations
Imaging: CT scan for staging and diagnosis; barium enema; erect CXR; abdominal radiograph.
Colonoscopy and sigmoidoscopy: For biopsy and diagnosis. Colonic lesion extraluminal localization can be facilitated by endoscopic tattooing.
Bloods: FBC, U&Es, clotting, and crossmatch prior to surgery. general evaluation of anesthesia. dosage of thromboprophylaxis, a preventive antibiotic. Preparing the bowels may be necessary.
After surgery: Better recuperation, prompt resumption of food and drink, mobilization, and effective analgesia. IV fluids are continued until oral intake is sufficient. Maintaining a precise record of fluid equilibrium is necessary. prevention of DVT. Revert to an NG tube and IV fluids until symptoms of post-operative ileus subside. In the postoperative phase, if there are any indications of a systemic disturbance, an anastomotic leak must be ruled out.
Procedure
Position: Lloyd Davis/modified lithotomy.
Access: Laparoscopic or midline incision methods. The contents of the abdomen are examined, looking for signs of liver metastases or swollen lymph nodes, and the small bowel is packed away from the left hemicolon.
The division of the peritoneal attachments at the white line of Toldt to the level of the splenic flexure mobilizes the descending colon. The spleen, left ureter, gonadal arteries, kidney, pancreas, and fourth portion of the duodenum must all be carefully avoided. Enough transverse colon mobilization occurs to allow for a tension-free anastomosis.
Ligation of vessels: The inferior mesentery artery and left colonic branches are located by dissecting the mesentery. The artery supply to the proximal and distal edges is then preserved by isolating, ligating, and dividing them.
Resection of bowel segment: The colonic segment and its accompanying mesentery are removed, and the bowel is clamped and separated, usually using linear staples.
Restoring intestinal continuity involves performing a handsewn or stapled anastomosis between the descending colon and the rectosigmoid colon. Closing the mesenteric defect prevents internal herniation.It is possible to create an aproximal defuncting stoma to shield the distal anastomosis.
Conclusion: Hemostasis is verified. Usually, a drain is installed. Sutures or clips are used to finish the skin closure once the abdominal wall is mass closed.
Complications
bleeding, infection, ileus, anastomotic leak, hernias, and thromboembolism are examples of visceral injuries.
- Published on
Surgery - Colorectal Resection, Low Anterior
Indications
Elective: Sigmoid or Rectal tumours, if adequate margins above the anal sphincter complex.
Anatomy
Starting at the level of the third sacral vertebra, the rectum (12 cm) descends and lies in the sacrococcygeal curve until it reaches the tip of the coccyx. After that, it abruptly turns back into the anal canal. The autonomic plexus, hypogastric nerves, and presacral (Waldeyer) fascia divide the rectum from the mesorectum. There are lymphatics and fatty tissue in it, and complete mesorectal excision has been demonstrated to lower the risk of local recurrence.
Vascular: The superior rectal artery receives blood from the inferior mesenteric artery to supply the upper rectum. The internal iliac artery is the source of the middle and inferior rectal arteries, which supply the lower rectum. The superior, middle, and inferior rectal vessels—the sites of portacaval anastomosis—are the drains of the rectal venous plexus.
Lymphatics: Drainage reaches the para-aortic nodes via following the inferior mesenteric artery.
Investigational studies
Imaging: CT, MRI, endorectal ultrasound: For planning/assessing appropriateness for anterior resection, as well as staging.
Pre-op: Chemoradiotherapy prior to surgery may be necessary (reduces local recurrence).
Bowel preparation, bloods: FBC, U&Es, clotting and crossmatch, general anaesthetic assessment and relevant investigations.
Close observation follows surgery. prevention of DVT.
Actions
The patient is arranged in an elongated Lloyd-Davis posture.
Incision: Laparoscopic procedures or lower or longer midline incisions are both possible.
Examining the abdominal cavity and determining the size and location of the tumor constitute the process of mobilizing the colon. The ureter and gonadal veins are carefully identified as the left colon and sigmoid mesentery are mobilized. Mobilization of the splenic flexure can be necessary.
The inferior mesenteric artery and vein are split, dissected, and ligated in order to mobilize the rectum.Using a stapler, the sigmoid, mesocolon, and sigmoid are separated, generally at the apex. The plane between the mesorectum and the sacral fascia can then be seen by pulling the rectum forward. The rectum is further dissected laterally and posteriorly, giving rise to a distinctive bilobed look.The plane between the anterior mesorectum and the seminal vesicles in the male and vagina in the female is then developed by the division of the peritoneum right above the apex of the rectovesical or rectouterine pouch.
Resection: A minimum of 2 cm of adequate clearance is required both proximally and distally from the tumor.
At the proximal and distal resection sites, clamps are positioned. Using a proctoscope, the lower rectum and anus are cleaned with an antiseptic solution. The bowel is then split between the proximal and distal clamps using a stapler.
Anastomosis: A circular staple gun is typically used by surgeons. An helper inserts the gun PR and advances the rod through the staple line's center. The anvil, which is the receiving end of the stapler gun, is wrapped with sutures around the proximal bowel end. The stapler is closed and fired to ensure that there is no twisting, resulting in the excision of a ring of intestine and the stapleing of the two ends together. The tissue "donuts" that are removed are sent to histology in addition to being inspected to make sure the rings are complete. By using air sufflation PR to conduct a leak test, the anastomosis can be verified.
Closure: Typically, a pelvic drain is left in place. There are non-absorbable stitches used to seal the abdominal wall. Sutures or clips finish the skin closing process. It is common practice to create a malfunctioning ileostomy to redirect stool contents during anastomotic recovery.
Complications
bleeding, ileus, anastomotic leak, infection, and abscess. The frequency and severity of bowel movements
Indications
Elective: Sigmoid or Rectal tumours, if adequate margins above the anal sphincter complex.
Anatomy
Starting at the level of the third sacral vertebra, the rectum (12 cm) descends and lies in the sacrococcygeal curve until it reaches the tip of the coccyx. After that, it abruptly turns back into the anal canal. The autonomic plexus, hypogastric nerves, and presacral (Waldeyer) fascia divide the rectum from the mesorectum. There are lymphatics and fatty tissue in it, and complete mesorectal excision has been demonstrated to lower the risk of local recurrence.
Vascular: The superior rectal artery receives blood from the inferior mesenteric artery to supply the upper rectum. The internal iliac artery is the source of the middle and inferior rectal arteries, which supply the lower rectum. The superior, middle, and inferior rectal vessels—the sites of portacaval anastomosis—are the drains of the rectal venous plexus.
Lymphatics: Drainage reaches the para-aortic nodes via following the inferior mesenteric artery.
Investigational studies
Imaging: CT, MRI, endorectal ultrasound: For planning/assessing appropriateness for anterior resection, as well as staging.
Pre-op: Chemoradiotherapy prior to surgery may be necessary (reduces local recurrence).
Bowel preparation, bloods: FBC, U&Es, clotting and crossmatch, general anaesthetic assessment and relevant investigations.
Close observation follows surgery. prevention of DVT.
Actions
The patient is arranged in an elongated Lloyd-Davis posture.
Incision: Laparoscopic procedures or lower or longer midline incisions are both possible.
Examining the abdominal cavity and determining the size and location of the tumor constitute the process of mobilizing the colon. The ureter and gonadal veins are carefully identified as the left colon and sigmoid mesentery are mobilized. Mobilization of the splenic flexure can be necessary.
The inferior mesenteric artery and vein are split, dissected, and ligated in order to mobilize the rectum.Using a stapler, the sigmoid, mesocolon, and sigmoid are separated, generally at the apex. The plane between the mesorectum and the sacral fascia can then be seen by pulling the rectum forward. The rectum is further dissected laterally and posteriorly, giving rise to a distinctive bilobed look.The plane between the anterior mesorectum and the seminal vesicles in the male and vagina in the female is then developed by the division of the peritoneum right above the apex of the rectovesical or rectouterine pouch.
Resection: A minimum of 2 cm of adequate clearance is required both proximally and distally from the tumor.
At the proximal and distal resection sites, clamps are positioned. Using a proctoscope, the lower rectum and anus are cleaned with an antiseptic solution. The bowel is then split between the proximal and distal clamps using a stapler.
Anastomosis: A circular staple gun is typically used by surgeons. An helper inserts the gun PR and advances the rod through the staple line's center. The anvil, which is the receiving end of the stapler gun, is wrapped with sutures around the proximal bowel end. The stapler is closed and fired to ensure that there is no twisting, resulting in the excision of a ring of intestine and the stapleing of the two ends together. The tissue "donuts" that are removed are sent to histology in addition to being inspected to make sure the rings are complete. By using air sufflation PR to conduct a leak test, the anastomosis can be verified.
Closure: Typically, a pelvic drain is left in place. There are non-absorbable stitches used to seal the abdominal wall. Sutures or clips finish the skin closing process. It is common practice to create a malfunctioning ileostomy to redirect stool contents during anastomotic recovery.
Complications
bleeding, ileus, anastomotic leak, infection, and abscess. The frequency and severity of bowel movements
- Published on
Surgery - Colorectal Resection, Right Hemicolectomy
Indications
Elective: Most frequently, appendiceal neoplasms, such as carcinoids >2 cm, or colonic neoplasms (caecum, ascending colon, or hepatic flexure). When hepatic flexure or transverse colon tumors are involved, extended right hemicolectomies are done. Crohn's disease is another.
Emergency: Recommended in cases of caecal volvulus or diverticulitis, as well as right colonic obstructive lesions, perforations, hemorrhages, or ischemia. In cases of severe appendicitis where the caecum is affected, ileocaecal resection or limited right hemicolectomy may be required.
Anatomy
From the caecum to the hepatic flexure, the ascending colon ascends (15 cm long). After that, it suddenly bends forward and to the left to form the transverse colon. Its anterior surface and sides are covered by the peritoneum, making it retroperitoneal. The right kidney, duodenum, and gonadal arteries, as well as the right ureter, are crucial structures to recognize and protect during surgery.
vascular The right colic, middle colic, and ileocolic arteries are the branches of the superior mesenteric artery that supply the arterial supply. Variable venous drainage enters the portal circulation mostly by the ileocolic, right colic, and middle colic veins.
Investigations
Imaging: CT scan, erect CXR, and abdominal radiograph: diagnosis and staging.
Colonoscopy: Polyp, tumor, inflammatory bowel, etc. diagnosis and biopsies.
Bloods: FBC, U&Es, clotting, crossmatch, preoperative.
evaluation of general anesthesia and thromboprophylaxis.
Post-op: Following elective surgery, improved recovery involves an early return to food and drink, prompt mobilization, effective analgesia, and close monitoring of the FBC, electrolytes, and urine output. Should there be indications of postoperative ileus, return to the traditional oral NG tube feeding regimen and gradually introduce liquids and solids as tolerated. Keep up the thromboprophylaxis.
Procedure
Lie down or do a modified lithotomy.
Access: Laparoscopic technique, transverse incision, or midline incision. The small intestine is packed up and the intra-abdominal contents evaluated.
Mobilize: Approaches from medial to lateral or lateral to medial are applied.
Lateral to medial: The division of the hepatocolic ligament mobilizes the hepatic flexure and inclines the right colon's lateral peritoneal attachments (white line of Toldt). identifying and avoiding the ureter, gonadal, and duodenum with caution. cautious removal of the right plane in front of Gerota's fascia. larger omentum dissection from the transverse colonic region that needs to be split.
Ligation of vessels: The ileocolic and right colic vessels are ligated and separated after the mesentery from the terminal ileum to the transverse colon is thoroughly dissected. It might also be necessary to divide the middle colic artery's right branches.
Resection of bowel segment: Clamps are positioned at both ends of the length that needs to be resected after measuring the amount of adequate clearance from the lesion. Linear staplers are frequently used to separate the gut, and the right colon is submitted for histology.
Restoring intestinal continuity: Healthy, well-vascularized, and tension-free bowel ends are required for bowel anastomosis. Using sutures or staples, the terminal ileum is anastomosed to the transverse colon in one or two layers, either side-to-side, end-to-end, or end-to-side. To stop internal herniation, the mesenteric defect is sealed.
Closure: A drain could remain in place. Mass closure after haemostasis confirmation.
Sutures or clips finish the skin closing process.
Complications include incisional hernias, thrombosis, ileus, abscess, wound infection, and anastomotic leak.
Indications
Elective: Most frequently, appendiceal neoplasms, such as carcinoids >2 cm, or colonic neoplasms (caecum, ascending colon, or hepatic flexure). When hepatic flexure or transverse colon tumors are involved, extended right hemicolectomies are done. Crohn's disease is another.
Emergency: Recommended in cases of caecal volvulus or diverticulitis, as well as right colonic obstructive lesions, perforations, hemorrhages, or ischemia. In cases of severe appendicitis where the caecum is affected, ileocaecal resection or limited right hemicolectomy may be required.
Anatomy
From the caecum to the hepatic flexure, the ascending colon ascends (15 cm long). After that, it suddenly bends forward and to the left to form the transverse colon. Its anterior surface and sides are covered by the peritoneum, making it retroperitoneal. The right kidney, duodenum, and gonadal arteries, as well as the right ureter, are crucial structures to recognize and protect during surgery.
vascular The right colic, middle colic, and ileocolic arteries are the branches of the superior mesenteric artery that supply the arterial supply. Variable venous drainage enters the portal circulation mostly by the ileocolic, right colic, and middle colic veins.
Investigations
Imaging: CT scan, erect CXR, and abdominal radiograph: diagnosis and staging.
Colonoscopy: Polyp, tumor, inflammatory bowel, etc. diagnosis and biopsies.
Bloods: FBC, U&Es, clotting, crossmatch, preoperative.
evaluation of general anesthesia and thromboprophylaxis.
Post-op: Following elective surgery, improved recovery involves an early return to food and drink, prompt mobilization, effective analgesia, and close monitoring of the FBC, electrolytes, and urine output. Should there be indications of postoperative ileus, return to the traditional oral NG tube feeding regimen and gradually introduce liquids and solids as tolerated. Keep up the thromboprophylaxis.
Procedure
Lie down or do a modified lithotomy.
Access: Laparoscopic technique, transverse incision, or midline incision. The small intestine is packed up and the intra-abdominal contents evaluated.
Mobilize: Approaches from medial to lateral or lateral to medial are applied.
Lateral to medial: The division of the hepatocolic ligament mobilizes the hepatic flexure and inclines the right colon's lateral peritoneal attachments (white line of Toldt). identifying and avoiding the ureter, gonadal, and duodenum with caution. cautious removal of the right plane in front of Gerota's fascia. larger omentum dissection from the transverse colonic region that needs to be split.
Ligation of vessels: The ileocolic and right colic vessels are ligated and separated after the mesentery from the terminal ileum to the transverse colon is thoroughly dissected. It might also be necessary to divide the middle colic artery's right branches.
Resection of bowel segment: Clamps are positioned at both ends of the length that needs to be resected after measuring the amount of adequate clearance from the lesion. Linear staplers are frequently used to separate the gut, and the right colon is submitted for histology.
Restoring intestinal continuity: Healthy, well-vascularized, and tension-free bowel ends are required for bowel anastomosis. Using sutures or staples, the terminal ileum is anastomosed to the transverse colon in one or two layers, either side-to-side, end-to-end, or end-to-side. To stop internal herniation, the mesenteric defect is sealed.
Closure: A drain could remain in place. Mass closure after haemostasis confirmation.
Sutures or clips finish the skin closing process.
Complications include incisional hernias, thrombosis, ileus, abscess, wound infection, and anastomotic leak.
- Published on
Surgery - Coronary Artery Bypass Graft
Indications
Triple coronary vessel disease, left main stem coronary artery disease, and two coronary vessel disease with a proximal left anterior descending artery lesion are the three primary anatomical reasons for CABG.
In these patients, CABG reduces angina and increases long-term survival.
Anatomy
After emerging from the ascending aorta, the right coronary artery passes anteriorly between the right auricle and the pulmonary trunk before descending via the atrioventricular groove.
It passes posteriorly and anastomoses with the left coronary artery at the inferior heart boundary.
The ascending aorta gives rise to the left coronary artery, which splits into the left anterior descending and left circumflex arteries in the atrioventricular groove after passing posteriorly between the pulmonary trunk and the left auricle. The internal mammary artery originates from the subclavian artery and descends behind the costal cartilages along the pleura. It finishes at the sixth intercostal gap, when it splits into the musculophrenic and superior epigastric arteries.
Investigational studies
Prior to surgery: ECG, echocardiography, coronary angiography, and thallium perfusion scintigraphy. Bloods: crossmatch, clotting, U&Es, and FBC. general evaluation of anesthesia.
Close observation in an ITU setting following surgery. meticulous follow-up.
Actions
A median sternotomy was made. The heart, coronary vessels, and large vessels are exposed and examined during pericardial dissection. Nowadays, less invasive thoracotomy incisions are made in an effort to lessen the morbidity associated with sternotomy.
"On Pump" CABG: Cardiopulmonary bypass machines are utilized during cardiac surgery to oxygenate and circulate blood. Perfusionists operate these machines. Blood is taken out of the right atrium and redirected into the ascending aorta via a venous cannula, causing systemic hypothermia and the administration of IV heparin. The heart is given a cardioplegic solution to cause a hypothermic cardioplegic arrest so that surgery can be done.
"Off pump" CABG: The heart is allowed to continue beating by applying tissue stabilisers, which are devices, to the surgical site.
Bypass graft: The internal mammary, radial, and, in rare cases, gastroepiploic arteries are used in arterial grafts. Beyond the stenosis or occlusion, the internal mammary is mobilized and anastomosed to the coronary artery. Through open or minimally invasive incisions, vein grafts are taken from the leg's long saphenous vein and anastomosed from the aorta to the coronary artery beyond the stenosis or occlusion.
Closure: The bypass circuit is turned off for the patient, enabling the heart to fill and begin contracting again. Sinus rhythm either spontaneously resumes with systemic rewarming or is restored via cardioversion. All cannulas are removed once adequate cardiac output, and protamine is given to reverse heparin. Two sizable thoracostomy drains are placed into the chest cavity and pericardium, and temporary pacing wires are put into the atrium and/or ventricles. The skin is closed and the sternum is sealed with broken steel wires.
Complications
Stroke and neurocognitive impairment, myocardial infarction during surgery, transient anomalies in conduction and arrhythmias (such as atrial fibrillation), pericardial effusion/tamponade, hemorrhage, mediastinitis, infection from a sternal wound, renal failure, and mortality.
Prognosis
A 2-3.5% operational mortality rate. Venous grafts show a 50–60% 10-year patency, compared to 90% for left internal mammary artery grafts. When CABG is contrasted with percutaneous coronary intervention, it has demonstrated a decreased requirement for revascularization and an improved prognosis for patients with diabetes who are older than 65.
Indications
Triple coronary vessel disease, left main stem coronary artery disease, and two coronary vessel disease with a proximal left anterior descending artery lesion are the three primary anatomical reasons for CABG.
In these patients, CABG reduces angina and increases long-term survival.
Anatomy
After emerging from the ascending aorta, the right coronary artery passes anteriorly between the right auricle and the pulmonary trunk before descending via the atrioventricular groove.
It passes posteriorly and anastomoses with the left coronary artery at the inferior heart boundary.
The ascending aorta gives rise to the left coronary artery, which splits into the left anterior descending and left circumflex arteries in the atrioventricular groove after passing posteriorly between the pulmonary trunk and the left auricle. The internal mammary artery originates from the subclavian artery and descends behind the costal cartilages along the pleura. It finishes at the sixth intercostal gap, when it splits into the musculophrenic and superior epigastric arteries.
Investigational studies
Prior to surgery: ECG, echocardiography, coronary angiography, and thallium perfusion scintigraphy. Bloods: crossmatch, clotting, U&Es, and FBC. general evaluation of anesthesia.
Close observation in an ITU setting following surgery. meticulous follow-up.
Actions
A median sternotomy was made. The heart, coronary vessels, and large vessels are exposed and examined during pericardial dissection. Nowadays, less invasive thoracotomy incisions are made in an effort to lessen the morbidity associated with sternotomy.
"On Pump" CABG: Cardiopulmonary bypass machines are utilized during cardiac surgery to oxygenate and circulate blood. Perfusionists operate these machines. Blood is taken out of the right atrium and redirected into the ascending aorta via a venous cannula, causing systemic hypothermia and the administration of IV heparin. The heart is given a cardioplegic solution to cause a hypothermic cardioplegic arrest so that surgery can be done.
"Off pump" CABG: The heart is allowed to continue beating by applying tissue stabilisers, which are devices, to the surgical site.
Bypass graft: The internal mammary, radial, and, in rare cases, gastroepiploic arteries are used in arterial grafts. Beyond the stenosis or occlusion, the internal mammary is mobilized and anastomosed to the coronary artery. Through open or minimally invasive incisions, vein grafts are taken from the leg's long saphenous vein and anastomosed from the aorta to the coronary artery beyond the stenosis or occlusion.
Closure: The bypass circuit is turned off for the patient, enabling the heart to fill and begin contracting again. Sinus rhythm either spontaneously resumes with systemic rewarming or is restored via cardioversion. All cannulas are removed once adequate cardiac output, and protamine is given to reverse heparin. Two sizable thoracostomy drains are placed into the chest cavity and pericardium, and temporary pacing wires are put into the atrium and/or ventricles. The skin is closed and the sternum is sealed with broken steel wires.
Complications
Stroke and neurocognitive impairment, myocardial infarction during surgery, transient anomalies in conduction and arrhythmias (such as atrial fibrillation), pericardial effusion/tamponade, hemorrhage, mediastinitis, infection from a sternal wound, renal failure, and mortality.
Prognosis
A 2-3.5% operational mortality rate. Venous grafts show a 50–60% 10-year patency, compared to 90% for left internal mammary artery grafts. When CABG is contrasted with percutaneous coronary intervention, it has demonstrated a decreased requirement for revascularization and an improved prognosis for patients with diabetes who are older than 65.
- Published on
Surgery - Endovascular Procedures
Indications
minimally invasive techniques, often known as "interventional radiology," are used to diagnose and treat venous or artery diseases endoscopically. carried out by a variety of specialists, such as gastroenterologists, cardiologists, neurosurgeons, radiologists, and vascular surgeons.
Endovascular procedures include :
Angioplasty and stents for arterial occlusive disease, such as those in the leg, renal, iliac, coronary, or carotid arteries.
Stenting of aneurysms, e.g. EVAR and popliteal aneurysms.coil embolization of aneurysms, such as those in the brain.
coil embolization of bleeding vessels, such as the duodenal artery when bleeding from a duodenal ulcer.
coil embolization of veins that have dilated, such as pelvic varicose veins and varicocoele.
catheter-directed thrombolysis or thrombectomy. tissue embolization, such as liver metastases through chemotherapy or embolization of uterine fibroids.
Shunts: in portal hypertension, transjugular intrahepatic portosystemic shunts (TIPS).
Filters: To avoid a venous embolism: vena cava inferior filters.
Vein ablation: Radiofrequency ablation of varicose veins or endovenous laser therapy (EVLT).
Benefits include: less pain; fewer incisions, frequently just a puncture wound; local anesthesia as opposed to general anesthesia; lower morbidity and mortality, particularly in the heart and lungs; and quicker recovery.
Actions
Access: The local anesthetic enters the body. Under ultrasound guidance, a guidewire and catheter are percutaneously cannulated and placed, usually into the femoral vein for venous circulation and the groin for arterial circulation. Options include the popliteal or subclavian arteries, or less frequently, the brachial or axillary arteries. The lower leg is used to access the long saphenous vein during treatment for varicose veins. If device implantation is to be done, antibiotics are given.
Navigation: A large variety of catheters and guidewires are available. The area of circulation under inquiry or treatment can be selectively catheterized thanks to experience, expertise, and knowledge of anatomy and imaging. Radio-opaque contrast is injected during an angiography procedure in order to plan, direct, and evaluate therapy.
Angioplasty: Lesion distance from access site, stenosis length, and native artery size are taken into consideration when choosing balloon catheters. Following the insertion of the balloon over the lesion, inflation of the balloon is carried out using contrast to enable fluoroscopic observation of the balloon's contour during dilatation, along with the monitoring of inflation pressures.
Stents: They can be self-expanding or balloon mounted. Stents come in many varieties, including as coated, drug-eluting, and baremetal. Certain types of stents, such as those put in the carotid artery, use embolic protection devices to trap plaque fragments that have come loose and could embolize and result in stroke.
Stent graft: An EVAR technique in which grafts are held up by a stiff stent framework.
Coils: Usually composed of nitinol, tungsten, or platinum. The coil is advanced to the intended intravascular site through the microcatheter by a delivery wire, often known as a "coil pusher." After being deployed, the flexible coils return to their former shape, preventing additional blood flow into the aneurysm or vessel.
Closure: The percutaneous catheter is removed, and the site is compressed manually or with the help of closure equipment.
Complications
Entry point: bleeding, pseudoaneurysm, arteriovenous fistula, infection in the groin, blockage of a vascular.
In the vessel during the insertion of a wire or catheter: embolism, perforation, false plane, and thrombosis.
Dissection, rethrombosis, intimal flap, perforation, restenosis, endoleak, graft infection, and stent migration can all occur at the intervention site.
Thrombosis and embolism are downstream.
Indications
minimally invasive techniques, often known as "interventional radiology," are used to diagnose and treat venous or artery diseases endoscopically. carried out by a variety of specialists, such as gastroenterologists, cardiologists, neurosurgeons, radiologists, and vascular surgeons.
Endovascular procedures include :
Angioplasty and stents for arterial occlusive disease, such as those in the leg, renal, iliac, coronary, or carotid arteries.
Stenting of aneurysms, e.g. EVAR and popliteal aneurysms.coil embolization of aneurysms, such as those in the brain.
coil embolization of bleeding vessels, such as the duodenal artery when bleeding from a duodenal ulcer.
coil embolization of veins that have dilated, such as pelvic varicose veins and varicocoele.
catheter-directed thrombolysis or thrombectomy. tissue embolization, such as liver metastases through chemotherapy or embolization of uterine fibroids.
Shunts: in portal hypertension, transjugular intrahepatic portosystemic shunts (TIPS).
Filters: To avoid a venous embolism: vena cava inferior filters.
Vein ablation: Radiofrequency ablation of varicose veins or endovenous laser therapy (EVLT).
Benefits include: less pain; fewer incisions, frequently just a puncture wound; local anesthesia as opposed to general anesthesia; lower morbidity and mortality, particularly in the heart and lungs; and quicker recovery.
Actions
Access: The local anesthetic enters the body. Under ultrasound guidance, a guidewire and catheter are percutaneously cannulated and placed, usually into the femoral vein for venous circulation and the groin for arterial circulation. Options include the popliteal or subclavian arteries, or less frequently, the brachial or axillary arteries. The lower leg is used to access the long saphenous vein during treatment for varicose veins. If device implantation is to be done, antibiotics are given.
Navigation: A large variety of catheters and guidewires are available. The area of circulation under inquiry or treatment can be selectively catheterized thanks to experience, expertise, and knowledge of anatomy and imaging. Radio-opaque contrast is injected during an angiography procedure in order to plan, direct, and evaluate therapy.
Angioplasty: Lesion distance from access site, stenosis length, and native artery size are taken into consideration when choosing balloon catheters. Following the insertion of the balloon over the lesion, inflation of the balloon is carried out using contrast to enable fluoroscopic observation of the balloon's contour during dilatation, along with the monitoring of inflation pressures.
Stents: They can be self-expanding or balloon mounted. Stents come in many varieties, including as coated, drug-eluting, and baremetal. Certain types of stents, such as those put in the carotid artery, use embolic protection devices to trap plaque fragments that have come loose and could embolize and result in stroke.
Stent graft: An EVAR technique in which grafts are held up by a stiff stent framework.
Coils: Usually composed of nitinol, tungsten, or platinum. The coil is advanced to the intended intravascular site through the microcatheter by a delivery wire, often known as a "coil pusher." After being deployed, the flexible coils return to their former shape, preventing additional blood flow into the aneurysm or vessel.
Closure: The percutaneous catheter is removed, and the site is compressed manually or with the help of closure equipment.
Complications
Entry point: bleeding, pseudoaneurysm, arteriovenous fistula, infection in the groin, blockage of a vascular.
In the vessel during the insertion of a wire or catheter: embolism, perforation, false plane, and thrombosis.
Dissection, rethrombosis, intimal flap, perforation, restenosis, endoleak, graft infection, and stent migration can all occur at the intervention site.
Thrombosis and embolism are downstream.
- Published on
Surgery - Gastrectomies
Indications
Elective: Severe peptic ulcer illness, benign and malignant tumors.
Emergency: bleeding or puncture that cannot be stopped with local anesthesia; stomach necrosis, such as that resulting from gastric volvulus.
Anatomy
The stomach has minor and greater curvatures and is separated into the cardia, fundus, body, antrum, and pylorus.
Vascular: The stomach is supplied by the gastroepiploic, short, left, and right gastric arteries (which are often derived from the hepatic artery). The celiac axis has all of these branches. The portal vein receives venous drainage from matching veins. The location of portal-systemic anastomosis is the gastro-oesophageal junction.
The lymphatic system is made up of several lymph nodes that follow arteries and give rise to lymph nodes in the stomach, colon, pancreaticoduodenal, splenic, gastroepiploic, portahepatic, paraoesophageal, and para-aortic regions.
nerve supply Terminal branches of the left and right vagus nerves are parasympathetic.
T6–T9 segments that travel via the celiac plexus and are dispersed across the larger splanchnic nerve are considered sympathetic.
Investigational studies
Imaging: If a perforation is suspected, perform an emergency AXR and CXR (erect). CT scan: For determining resectibility and staging.
Endoscopy: endoscopic ultrasound tumor staging, optical generalization for biopsies.
Pre-op: FBC, U&Es, clotting, and crossmatch are the appropriate blood types. Before a final procedure, a staging laparoscopy may be carried out on stomach tumors to determine their resectibility.
After surgery: IV fluids, urine catheter, and NG or nasojejunal tube. prevention of DVT. Parenteral feeding could be required in the first several days following surgery.
Actions
Cutting: Open: Usually a diagonal "sabreslash" incision or an upper midline incision. increased the amount of laparoscopic procedures.
Gastrectomy types:
Subtotal distal gastrectomy (Billroth I). After reconstruction, the proximal stomach's smaller curve is anastomosed to the duodenum. less frequently carried out these days.
Polya partial gastrectomy, or Billroth II: A gastrojejunostomy is created when the proximal gastric remnant is anastomosed to the jejunum following distal stomach resection. A blind loop is created by the oversewing of the duodenum at its proximal end. Bile reflux is a possible side effect of Billroths I and II.
Roux-en-Y partial gastrectomy: The jejunum is divided after the distal stomach is removed, with the proximal jejunum being anastomosed further along the jejunum to form a Roux loop and the distal end being anastomosed to the gastric remnant.
Complete gastrectomy: The entire stomach is removed, and typically a Roux-en-Y loop is used to anastomose the distal oesophagus to the jejunum in order to restore intestinal continuity. The terms "D1 or D2 gastrectomies" refer to the radicality of lymph node clearance. While D2 entails more radical nodal clearance (coeliac, splenic, and common hepatic nodes), D1 requires clearing the N1 or first tier of perigastric nodes. It is possible to do distal pancreatectomy and splenectomy, although doing so raises the rate of operational death (from 4% to 15%) without improving cancer survival.
Oesophagogastrectomy in two phases: carried out for oesophageal or gastrooesophageal junction tumors. The chest phase includes oesophagectomy, lymphadectomy, gastric pull up into the chest, and construction of a gastric tube conduit after abdominal gastric mobilization and lymphadenectomy.
Complications
Early symptoms include bleeding, fistula formation, pancreatitis, anastomotic leak, infection, and duodenal stump leakage.
Long-range: Vitamin B12 deficiency, dumping syndromes (early and late), weight loss, reflux, diarrhea, stomal ulceration, blind loop syndrome, anemia, and metabolic bone disease
Indications
Elective: Severe peptic ulcer illness, benign and malignant tumors.
Emergency: bleeding or puncture that cannot be stopped with local anesthesia; stomach necrosis, such as that resulting from gastric volvulus.
Anatomy
The stomach has minor and greater curvatures and is separated into the cardia, fundus, body, antrum, and pylorus.
Vascular: The stomach is supplied by the gastroepiploic, short, left, and right gastric arteries (which are often derived from the hepatic artery). The celiac axis has all of these branches. The portal vein receives venous drainage from matching veins. The location of portal-systemic anastomosis is the gastro-oesophageal junction.
The lymphatic system is made up of several lymph nodes that follow arteries and give rise to lymph nodes in the stomach, colon, pancreaticoduodenal, splenic, gastroepiploic, portahepatic, paraoesophageal, and para-aortic regions.
nerve supply Terminal branches of the left and right vagus nerves are parasympathetic.
T6–T9 segments that travel via the celiac plexus and are dispersed across the larger splanchnic nerve are considered sympathetic.
Investigational studies
Imaging: If a perforation is suspected, perform an emergency AXR and CXR (erect). CT scan: For determining resectibility and staging.
Endoscopy: endoscopic ultrasound tumor staging, optical generalization for biopsies.
Pre-op: FBC, U&Es, clotting, and crossmatch are the appropriate blood types. Before a final procedure, a staging laparoscopy may be carried out on stomach tumors to determine their resectibility.
After surgery: IV fluids, urine catheter, and NG or nasojejunal tube. prevention of DVT. Parenteral feeding could be required in the first several days following surgery.
Actions
Cutting: Open: Usually a diagonal "sabreslash" incision or an upper midline incision. increased the amount of laparoscopic procedures.
Gastrectomy types:
Subtotal distal gastrectomy (Billroth I). After reconstruction, the proximal stomach's smaller curve is anastomosed to the duodenum. less frequently carried out these days.
Polya partial gastrectomy, or Billroth II: A gastrojejunostomy is created when the proximal gastric remnant is anastomosed to the jejunum following distal stomach resection. A blind loop is created by the oversewing of the duodenum at its proximal end. Bile reflux is a possible side effect of Billroths I and II.
Roux-en-Y partial gastrectomy: The jejunum is divided after the distal stomach is removed, with the proximal jejunum being anastomosed further along the jejunum to form a Roux loop and the distal end being anastomosed to the gastric remnant.
Complete gastrectomy: The entire stomach is removed, and typically a Roux-en-Y loop is used to anastomose the distal oesophagus to the jejunum in order to restore intestinal continuity. The terms "D1 or D2 gastrectomies" refer to the radicality of lymph node clearance. While D2 entails more radical nodal clearance (coeliac, splenic, and common hepatic nodes), D1 requires clearing the N1 or first tier of perigastric nodes. It is possible to do distal pancreatectomy and splenectomy, although doing so raises the rate of operational death (from 4% to 15%) without improving cancer survival.
Oesophagogastrectomy in two phases: carried out for oesophageal or gastrooesophageal junction tumors. The chest phase includes oesophagectomy, lymphadectomy, gastric pull up into the chest, and construction of a gastric tube conduit after abdominal gastric mobilization and lymphadenectomy.
Complications
Early symptoms include bleeding, fistula formation, pancreatitis, anastomotic leak, infection, and duodenal stump leakage.
Long-range: Vitamin B12 deficiency, dumping syndromes (early and late), weight loss, reflux, diarrhea, stomal ulceration, blind loop syndrome, anemia, and metabolic bone disease
