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Chapter 19: Miscellaneous
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93
Figure 3: This is a stulogram study with evidence of irregular tract in the soft tissue of perianal area at 3’o clock position which extends superiorly,
Figure 4: This is a sinogram study with contrast tracking to a blind sinus tract in the perianal area not making any communication with the anal canal
medially and anteriorly to communicate with the anal canal suggestive of Fistula-in-ano.
suggestive of sinus at perianal region
94
Section 3: X-rays
DISTAL LOOPOGRAM
It is an X-ray investigation in which dye is pushed through
an articially formed stoma (ileostomy/colostomy) and
ndications
I
To check for patency of distal GI tract before closing the
stoma
To look for possibility of Inammatory bowel disorders
To look for any growth in intestine lumen which may
cause obstruction distally.
serial X-rays are taken to nd obstruction or any other
pathology in distal GI tract till anal opening.
ethod
M
A Foley catheter is inserted into the stoma opening of
distal bowel loop and the bulb is partially inated to keep
it in place and form a seal
Contrast dye usually Urogran is pushed through it and
serial X-ray lms are taken at dierent intervals to check
the patency of distal GI tract.
Figure 5: This is a digital distal loopogram with X-ray lms taken at dierent intervals and the last lm taken after voiding of faeces showing the normal
passage of contrast dye from the initial point to the anal opening with no signicant pathology in ascending colon, transverse colon, descending colon
and sigmoid colon suggestive of a normal distal loopogram study
Chapter 19: Miscellaneous
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FOREIGN BODY XRAYS
Figure 6: This is a digital skiagram of abdomen AP view with lower part of chest and upper part of pelvis showing two radiopaque shadows in right side
of abdominal cavity one at the level of L4–L5 vertebra and other at the level of coccyx suggestive of metallic foreign bodies most probably in GI tract (This
X-ray is actually of a psychiatric patient who had a habit of eating unusual things)
95
Figure 7: This is a plain skiagram of right foot AP and lateral view showing the presence of a metallic foreign body in the posterior aspect of foot
at the level of calcaneum bone (This foreign body is actually a bullet as this patient suered a rearm injury)
96
.
Section 3: X-rays
Figure 8: It is a plain skiagram of foot AP and lateral view showing the presence of a sharp pointed pin like object in the plantar aspect of foot suggestive
of a metallic foreign body in the foot. The artery forceps in this X-ray have been used to determine the exact location of the foreign body. The ideal surgical
treatment is the removal of foreign body under C-arm guidance
SECTION
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OpEraTIvE STEpS
4
CHAPTERS
Chapter 20: Introduction
Chapter 21: Abscess Drainage
Chapter 22: Nerves and Vessels
Chapter 23: Head and Neck
Chapter 24: Gastrointestinal
Chapter 25: Hepatobiliary
Chapter 26: Chest Wall
Chapter 27: Urology
Chapter 28: Miscellaneous
INTrOduCTION
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CHAPTER
20
ere are several things to remember before describing
any operative step.
PREOPERATIVE PREPARATION
Clinical evaluation: History + Physical Examination
+ Routine Blood Tests +/- Chest X-ray, ECG, 2D Echo
Part preparation: Removal of hair by epilating cream
is a better method than shaving as it may cause
microscopic cuts which may cause infection.
If shaving needs to be done, it should be done in
morning hours prior to surgery
Preoperative antibiotics
Nil per oral (NPO): Patient should have been fasting
for 6–8 hours prior to surgery especially for general
anesthesia
Written and informed consent
Tetanus prophylaxis – After taking proper history of
immunization
Pre anesthetic check up.
PREPARATION ON OT TABLE
Position of the patient
Type of anesthesia to be given
Painting of operative eld
Usually done with one coat of savlon, one coat of
spirit and 2–3 coats of betadine at last
Draping of operative eld (Exposure of operative eld
only).
SUTURES USED IN CLOSING OF
DIFFERENT LAYERS OF INCISION
is is a basic concept and can be used at the end of
each operative note if a detailed description of closure of
incision layers is required.
Layer of incision Suture used Preferably
Skin Nylon Interrupted mattress
Subcutaneous tissue Chromic / Vicryl Interrupted simple
EOA/Rectus sheath/Fascia Vicryl / PDS Continuous
Muscle Vicryl / Chromic Interrupted
Peritoneum Vicryl Continuous
Size of these sutures may vary with the type and size of
wound.
Dierent surgeons may use dierent types of sutures for
dierent layers depending on their personal preference.
100
Section 4: Operative Steps
omplications
C
These are some of the complications which can be mentioned in any major surgery.
Groups Complications
Chest Complications
General
Wound Complications
Intraoperative complications
Specic surgery-related complications
Bronchopneumonia
Postoperative lung atelectasis
Deep vein thrombosis with pulmonary embolism
Aspiration
Fever
Septicemia
Urinary retention (spinal anesthesia)
Pain
I.V cannula thrombophlebitis
Injection related abscess
Wound dehiscence
Wound infection
Cellulitis
Incisional hernia formation
Stitch abscess
Bleeding from vessels
Injury to surrounding structures like vessels, bowel, etc.
Electrocautery related thermal injuries
Slipping of sutures (After ligating pedicles of major organs)
Described individually in each operative step
ABSCESS DRAINAGE
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Chapter
21
An abscess is a localized collection of pus which is generally
associated with signs of inammation.
HILTON’S METHOD OF ABSCESS
DRAINAGE
When the abscess is situated in areas with major nerves
and vessels then there is a possibility of injury to the
underlying structures during abscess drainage
To prevent this, abscess is drained using Hilton’s
method
Figure 1: Hilton’s method of abscess drainage
Most commonly performed in areas like neck, axilla
and groin.
ANESTHESIA
Local anesthesia
Regional anesthesia
General anesthesia.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
The skin and subcutaneous tissues are incised with a stab
knife (Blade No.11)
The sinus forceps is introduced in the cavity with the
closed jaws
Then the blades are opened to widen the opening to
drain the pus
The sinus forceps is taken out with its jaw opened so
that no vital structure is damaged between the blades of
forceps
Finger may be introduced inside the cavity to break the
loculi
The abscess cavity is then washed with hydrogen
peroxide and povidone-iodine solution
The cavity is packed with povidone-iodine soaked roller
bandage to obliterate the dead space and provide
compression to stop the bleeding
Sterile dressing is done.
102
Section 4: Operative Steps
C
omplications
Damage to the vitals structures present below the abscess
cavity
Bleeding from abscess cavity
Recurrence of abscess
Sinus formation.
DIFFERENT TYPES OF ABSCESS
A. Parotid Abscess
Start incision anterior to tragus and move towards
mastoid taking it downwards along the anterior
border of SCM in the upper part of the neck.
C. Breast Abscess
Usually para-areolar or sub-mammary incision is
preferred
A B
Figure 4: (A) Incisions: Radial, peri-areolar, submammary; (B) Exploration
(gentle) with a nger or forceps
D. Acute Paronychia
It is infection around the nail
Incision is given at the angle of nail and the involved
corner of the nail is excised
Figure 2: Parotid abscess
B. Anorectal Abscess
A cruciate incision is given over the most uctuant
part of the swelling and the corners of the skin aps
are excised to deroof the abscess cavity
A
B
Figure 5: Acute paronychia
Figure 3: Anorectal abscess
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