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Chapter 21: ABSCESS DRAINAGE
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E. Axillary Abscess
Incision is given half an inch behind the anterior axillary fold
Figure 6: Axillary abscess
F. Neck Abscess
Skin crease incision given parallel to anterior border of the SCM of the aected side.
103
Figure 7: Surgical incisions used to approach deep neck injection
ey Point
K
The incision over an abscess is usually given over the most uctuant and the most dependent part of it so that spontaneous drainage
occurs in postoperative period thereby preventing pus accumulation in the abscess cavity
Nerves aNd vessels
Chapter
22
LUMBAR SYMPATHECTOMY
ndications
I
Peripheral vascular disease involving medium and small
vessels of lower limb, e.g. Buerger’s disease
Hyperhydrosis
Raynaud’s disease
Acrocyanosis
Frost bite.
ANESTHESIA
General anesthesia
Spinal anesthesia
POSITION
Semilateral position to expose flank by tilting
patient towards opposite side with the help of sand
bags.
Figure 1: Lumbar sympathectomy: Relations of the sympathetic trunks
Chapter 22: Nerves and Vessels
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105
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Oblique incision is given from the tip of 12th rib to the
lateral border of rectus at the level of umbilicus
Abdominal muscles including EO, IO, TA are split in the
line of incision taking care not to open the peritoneum
Peritoneum is mobilized by retracting the peritoneal sac
medially to expose the retroperitoneal space
The lumbar sympathetic chain is identied by following
features:
¾ Glistening white appearance
¾ Thick cord like
¾ Lies in groove between psoas muscle and lumbar
vertebral bodies
¾ Presence of ganglia
¾ Bounded by IVC on right side and aorta on the left.
Dissection of sympathetic chain is done using right
angle forceps to reach the 4th ganglia behind the
common iliac vessels which is divided at this point
Haemostasis is achieved
Incision is closed in layers.
Spinal cord
(T
– L
9
omplications
C
Breach of peritoneum
Injury to ureter, genital vessels, duodenum, etc.
Bleeding (injury to lumbar veins)
Retroperitoneal hematoma
Incomplete sympathectomy.
ey Points
K
1st to 4th lumbar ganglia are removed for complete
sympathetic denervation of lower limb but if bilateral
procedure is done, then 1st lumbar ganglion is spared to
prevent sterility due to failure of ejaculation
Distance between 1st and 4th lumbar ganglia is
approximately 10 cm
1st lumbar ganglion lies under cover of crus of diaphragm
while 4th lumbar ganglion is covered by common iliac vessels
It is a preganglionic surgery for vessels below the knee
because the sympathetic bers supplying these vessels
have relay in the sacral ganglia which are not disturbed
2
TRENDELENBURG OPERATION
ndication
I
Varicosity of long saphenous vein due to incompetence of saphenofemoral junction valve.
Figure 2: Trendelenburg operation
106
Section 4: Operative Steps
RELATIVE CONTRAINDICATIONS
Bleeding disorders
Pregnancy
Deep venous thrombosis.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Oblique incision is given below and parallel to medial
half of inguinal ligament medial to femoral pulsations
Incision is deepened to reach long saphenous vein
where it enters the cribriform fascia
Three tributaries of long saphenous vein are ligated
and divided which include
¾ Supercial epigastric vein
¾ Supercial external pudendal vein
¾ Supercial circumex iliac veins
The junction of LSV with femoral vein is identied.
The LSV is then doubly ligated and divided close to this
junction (ush ligation)
The incision is closed in layers and crepe bandaging is
done on the lower limb.
CENTRAL VENOUS LINE
ANESTHESIA
Spinal/general anesthesia.
POSITION
Supine with legs apart.
omplications
C
Hematoma formation
Recurrence
Pain.
ey Points
K
Stripping of LSV is not preferred nowadays and the LSV is
left in situ
In Cockett and Dodd’s operation, ligation of perforators at
subfascial level is done
Any residual varicosities is treated later on by injection
sclerotherapy.
A. SUBCLAVIAN APPROACH
ndications
I
Measuring CVP and PCWP
For prolonged parenteral nutrition
For rapid i.v transfusion (e.g. in shock)
When peripheral venous access is dicult.
Figure 3: Central venous catheter insertion techniques
Chapter 22: Nerves and Vessels
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107
ontraindication
C
Bleeding disorders
Skin infections at site of entry
Cervical spine fracture/clavicular fracture (Relative
Contraindication).
POSITION
Supine with head tilted 5° down to the horizontal with
sand bag placed between shoulders and head turned
to opposite side.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Skin below the junction of medial 2/3rd and lateral 1/3rd
of right clavicle is inltrated with 1% lignocaine
A 20-gauge needle with a 10 ml syringe is inserted at
this point at 30° angle to the horizontal with needle
pointing towards the suprasternal notch/tip of other
shoulder
A negative pressure is maintained while inserting the
needle till there is free-ow of venous blood in the syringe
A guide wire is then introduced through the other port in
the introducer needle
The needle is removed keeping the guide wire inside the
vein
The dilator is passed over the guide wire to dilate the skin
The central venous catheter is passed over the guide wire
to reach the upper part of superior vena cava following
which the guide wire is removed
Catheter is xed to the skin using silk 2-0 TCN suture and
the position of the catheter tip may be conrmed by a
chest X-ray.
omplications
C
Pneumothorax
Subclavian artery puncture (Immediately withdraw the
needle and press the entry point rmly for few minutes)
Air embolism
Sepsis
Venous thrombosis.
POSITION
Supine with head tilted down 5° to the horizontal with slight
neck tilt towards opposite side to distend the neck veins.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Skin at the apex of triangle formed by the 2 heads of SCM
muscle and the clavicle is injected with 1% lignocaine
A 20-gauge needle with a 10 ml syringe is inserted
at 45° to the horizontal at this point directed laterally
downwards and backwards pointing towards the nipple
of the same side
The position of needle is then conrmed by aspiration of
blood
The remaining procedure is same as described in subclavian
approach.
omplications
C
Same as that described in subclavian approach
Carotid artery puncture.
VENESECTION
It is a surgical procedure of giving i.v. infusion through a
peripheral vein by surgically exposing it.
ndications
I
When neither peripheral nor central venous cannulation
is possible
¾ Severe hypovolemic shock after burn, hemorrhage or
MI
¾ Septic shock
Prior to major surgeries if a patient cannot aord a central
venous line
For providing parenteral nutrition in some cases.
ANESTHESIA
Local anesthesia.
B. INTERNAL JUGULAR APPROACH
Indications and Contraindications
Same as that described in subclavian approach
SITES FOR VENESECTION
Long saphenous vein near median malleolus
Cephalic vein in delto-pectoral groove
Medial cubital vein in the cubital fossa.
108
Section 4: Operative Steps
Figure 4: Venesection
ethods
M
Antiseptic dressing and draping of the operative eld is done
2% xylocaine is inltrated at incision site
A small 1.5 cm transverse incision is given perpendicular to the long axis of vein
Vein is dissected by ne mosquito artery forceps
Two silk sling ligatures are passed around the vein and the distal ligature is tied
A small nick is given in the vein between the ligatures through which i.v. cannula or infant feeding tube is passed proximally
The proximal ligature is tied to x the cannula inside the vein
The infusion line is connected and the main incision is closed.
omplications
C
Thrombophlebitis
Sepsis
Localized edema
Abscess formation
Sinus formation.
Head and neck
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PAROTIDECTOMY
Chapter
23
TYPES
1. Superficial parotidectomy: Removal of superficial lobe of parotid with conservation of facial
nerve
Figure 1: Supercial parotidectomy
SUPERFICIAL PAROTIDECTOMY
ndications
I
Pleomorphic adenoma/mixed parotid tumor—most common
Inammatory disease, e.g. Chronic parotitis, parotid abscess
Any tumor arising from supercial lobe.
2. Total parotidectomy: Removal of supercial and deep
lobe of parotid with conservation of facial nerve
3. Radical parotidectomy: Removal of superficial and
deep lobe of parotid with sacrice of facial nerve with
radical neck dissection.
110
ontraindication
C
Multiple parotid cysts in HIV patient (high chance of
recurrence).
ANESTHESIA
General anesthesia.
POSITION
Supine with slight extension of neck with head turned
to opposite side and resting on a head ring
A sand bag is placed below the shoulder blade
Head end is elevated by 15° to reduce venous conges-
tion.
Section 4: Operative Steps
Figure 2: ‘S’ shaped incision
ethods
M
Antiseptic dressing and draping of the operative eld is
done
An ‘S’ shaped incision is given
¾ below zygomatic arch
¾ extending in front of tragus
¾ continuing around the ear lobule
¾ moving backwards to mastoid process
¾ Curves downwards for a short distance along the
anterior border of SCM
Skin aps are raised
¾ anteriorly up to anterior border of parotid gland
¾ superiorly up to zygomatic arch
¾ posteriorly to expose SCM and mastoid process
The external jugular vein is dissected, ligated and
divided at lower pole of the gland
The dissection is done between anterior border of SCM
and posterior border of parotid gland to reach up to the
mastoid process
The temporo-parotid fascia is incised along the anterior
border of mastoid process to reach a plane between
external auditory meatus and the gland
The facial nerve is identied
¾ Emerging from stylomastoid foramen in front of
styloid process
¾ At the junction of cartilaginous and bony part of EAC
Dissection of supercial parotid lobe from the deep lobe
is done in the plane of facial nerve (Fasciovenous plane
of Patey)
All the nerve branches are dissected and parotid duct is
ligated at anterior border of masseter muscle to remove
the supercial part of gland completely
Hemostasis is achieved and suction drain is placed in the
wound
Incision is closed in layers and compressive dressing is
done.
omplications
C
Injury to facial nerve, usually temporary due to
neuropraxia
Bleeding
Parotid stula
Frey’s syndrome.
ey Points
K
Frey’s syndrome (Dupuy’s syndrome or Auriculotemporal
syndrome)
¾ Due to iatrogenic damage to auriculotemporal nerve
¾ Redness and sweating on cheek area adjacent to ear
(focal hyperhydrosis) in response to gustatory stimuli
Procedures to correct post-parotidectomy facial palsy
¾ Nerve graft
¾ Sling operations
¾ Conservative management.
THYROIDECTOMY
TYPES
1. Hemithyroidectomy: Removal of involved lobe and
isthmus.
2. Total thyroidectomy: En block removal of thyroid gland
along with isthmus.
3. Subtotal thyroidectomy: Removal of total thyroid gland
leaving about 2 gm of thyroid tissue on both sides.
4. Near-total thyroidectomy: Removal of complete thyroid
tissue leaving some part of uninvolved lobe.
Chapter 23: Head and Neck
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Figure 3: Thyroidectomy
Figure 4: Types of thyroidectomy
ndications
I
Proven or potential malignancy: Papillary, follicular and
medullary carcinoma
Hyperthyroidism in some patients:
¾ Young patients with toxic solitary nodule
¾ In specic cases of Graves disease
¾ Patients with retrosternal extension of thyroid with
obstructive symptoms
¾ Patients with thyroid storm
Patients of multinodular goitre with pressure symptoms.
ANESTHESIA
General anesthesia.
POSITION
Supine with neck extended and sand bag between
shoulder blades with about 10° head up tilt of OT table
to reduce venous congestion.
ethods
M
Antiseptic dressing and draping of the operative field is
done from the level of chin to upper chest
Cervical collar incision is given 2 cm above the
suprasternal notch extending from posterior border of
one SCM muscle to the posterior border of other side.
The skin incision is marked by pressing a thread over
the desired incision area (Garrotte mark)
Skin and platysma are incised to expose the investing
layer of deep cervical fascia
Skin flaps are raised
¾ Upper flap till the upper border of thyroid cartilage
¾ Lower flap up to the suprasternal notch
Investing layer of deep cervical fascia is incised in
the midline and the anterior jugular veins are ligated
and divided
The fascia along with strap muscles are retracted to
expose the lateral lobes of thyroid gland
The pre-tracheal fascia over the thyroid gland is
incised and blunt dissection using finger is done
between this fascia and the gland
The thyroid lobes are mobilised medially and the
middle thyroid vein is identified, ligated and divided
The superior thyroid vessels are dissected close to
upper pole of lobe and the artery and vein are ligated
separately avoiding any damage to external laryngeal
nerve
Inferior thyroid artery and vein is identified and
ligated away from the lower pole avoiding any injury to
the recurrent laryngeal nerve
The same procedure is performed on the other side
The thyroid isthmus is dissected from trachea and the
thyroidea ima artery is ligated and divided, if present
Hemostasis is achieved and suction drain is placed
The wound is closed in layers.
111
112
omplications
C
A. Early
¾ Neck hematoma with subsequent airway
compression
¾ Unilateral or bilateral superior/ recurrent laryngeal
nerve injury
¾ Thyroid crisis
¾ Tetany due to parathyroid injury
B. Late
¾ Wound infections
¾ Hypoparathyroidism
¾ Hypertrophic scar
¾ Thyroid insuciency
¾ Stitch granulomas.
ey Points
K
Mnemonic for indications of surgery:
¾ C-Cosmesis
¾ R-Retrosternal extension
¾ A-Anxiety (symptomatic)
¾ M-Malignancy
¾ P-Pressure symptoms
Now the current concept is that the inferior thyroid
vessels should be divided as close to the thyroid gland
as possible in order to prevent devascularization of
parathyroid glands.
In case of accidental removal of parathyroid gland with the
thyroid tissue, it should be divided into 1 mm fragments
and should be re-implanted in sternocleidomastoid
muscle.
Section 4: Operative Steps
Figure 5: Tracheostomy
TYPES
Depending upon the site of tracheostomy:
High tracheostomy: Above the level of isthmus of thyroid
gland
Mid-tracheostomy: At the level of isthmus of thyroid gland
Low tracheostomy: Below the level of isthmus of thyroid gland.
POSITION
Supine with hyperextension of neck with a sand bag
placed in between the shoulder blades.
TRACHEOSTOMY
ndications
I
Upper airway obstruction in case of:
¾ Maxillofacial injuries
¾ Laryngeal diphtheria
¾ Foreign body in larynx
¾ Carcinoma of upper airway tract
Comatose patients following severe head injury
Respiratory failure
Severe tetanus with frequent spasm
Following surgeries of neck like laryngectomy, laryngo-
pharyngectomy.
ANESTHESIA
Local anesthesia (1% lignocaine hydrochloride).
ethod
M
Antiseptic dressing and draping of the operative eld is
done
Incision
¾ Emergency cases: Vertical incision is given below
thyroid cartilage extending upto 2 cm above the
suprasternal notch
¾ Elective cases: 4–5 cm transverse incision is given 2
cm above the suprasternal notch
The platysma and the deep fascia are incised in the
midline and the strap muscles (sternohyoid, sternothyroid
muscle) are retracted laterally
Pre-tracheal fascia is incised and the thyroid isthmus is
identied, ligated and divided thereby exposing the trachea
1% lignocaine is injected in anterior tracheal wall to
suppress the cough reex
After stabilizing the trachea, a stab incision is given over
the 2nd and 3rd tracheal ring which is then dilated with
the help of a tracheal dilator
The tracheostomy tube is inserted and the balloon is
inated in case of a cued tracheostomy tube
The deep fascia and skin is closed and tube is kept in
place with the help of tapes around the neck
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