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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.
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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.
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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
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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.
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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.
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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).
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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.
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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.
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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.
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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.
