Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 434 - файл
.pdf
Chapter 23: Head and Neck
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
113
omplications
C
Immediate
¾ Hemorrhage
¾ Surgical emphysema
¾ False tract
¾ Injury to esophagus
Early
¾ Blockage of tube
¾ Reactionary hemorrhage
Late
¾ Tracheal stenosis (specially with a cued tube)
¾ Tracheo-cutaneous stula
¾ Infection.
dvantages of Tracheostomy
A
Eliminates anatomical dead space and improves
pulmonary ventilation
Decreases the risk of aspiration
Provides a denitive airway
Tracheal secretions can be easily suctioned
ey Points
K
The thyroid isthmus lies at the level of 2nd, 3rd and 4th
tracheal rings
Tracheostomy care
¾ Humidication of inhaled air
¾ Nebulization by saline and mucolytic agents
¾ Aseptic suction through the tube
¾ Changing the tube when blocked
¾ Regular dressing around the tube
¾ Decannulation when the need for tracheostomy is
over.
Gastrointestinal
Chapter
24
APPENDICECTOMY
ndications
I
Acute appendicitis
Recurrent/chronic appendicitis
Mucocele of appendix
Appendicular perforation
Appendicular abscess
Carcinoid tumor of appendix (less than 2 cm) not
involving cecal wall.
ontraindication
C
Appendicular mass.
ANESTHESIA
Spinal/general anesthesia.
POSITION
Supine.
Figure 1: Appendicectomy
Chapter 24: Gastrointestinal
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
115
ethods
M
Antiseptic dressing and draping of the operative eld is done
Incision
¾ Mc Burney’s Gridiron incision (preferred): 5 to 6 cm
incision given perpendicular to a line (spino-umbilical
line) joining umbilicus to ASIS at the junction of its
medial 2/3rd and lateral 1/3rd
¾ Rutherford Morrison incision: Same as Gridiron
incision with cutting of internal oblique and transversus
muscle instead of splitting them
¾ Lanz’s incision: Transverse skin crease incision
¾ Right lower paramedian incision
¾ Lower midline incision
Skin and subcutaneous tissue are retracted to reach
external oblique aponeurosis
The aponeurosis is divided in the direction of incision
with the help of scissors to expose internal oblique muscle
and transversus abdominis muscle
The bres of these muscles are split (cut in case of
Rutherford Morrison incision) and retracted with the help
of two Langenbach’s retractors to expose the peritoneum
Peritoneum is incised along the line of incision by lifting it
with the help of two hemostatic artery forceps
Cecum is identied by its pale color, tenia coli and absence
of mesentery
Appendix is identied by tracing tenia coli along the wall
of cecum
Appendix is held with the help of non-traumatic Babcock
forceps applied one at its tip and the other at its base
Mesoappendix is divided by passing a ligature around it
with the help of artery forceps to free the appendix from it
The base of the appendix is crushed by hemostatic artery
forceps near the cecal wall and is transxed or ligated using
vicryl or chromic suture
Another hemostatic forceps is applied 0.5 cm distal to the
crushed site and a knife is used to divide the appendix at
this point
Stump of appendix is swabbed with povidone iodine
solution (chemical cauterization)
Burying the base of appendix by taking purse-string suture
in cecum is not done nowadays
Hemostasis is achieved
Terminal ileum is explored up to 2 feet from ICJ to look for
Meckel’s diverticulum
An abdominal drain is placed and the wound is closed in layers.
ey Points
K
Retrograde appendicectomy: Dissecting the appendix
starting from its base towards the tip in dicult
conditions like dense adhesions of appendix to its
surrounding structures
Appendix should not be crushed at the base when:
¾ Perforation at base of appendix
¾ Gangrenous appendix
Appendicular lump is managed conservatively by
“Ochsner Sherren regimen” till the lump disappears
clinically, after which interval appendicectomy can be
done after 6-8 weeks
Signs of appendicitis:
¾ Rovsing’s sign: Pain in right iliac fossa while palpating
left iliac fossa
¾ Obturator sign: Pain on internal rotation of right hip
suggestive of pelvic appendix
¾ Iliopsoas sign: Pain on right hip extension suggestive
of retrocecal appendix
¾ Aaron sign: Referred pain felt in epigastrium upon
continuous rm pressure over McBurney’s point
¾ Ten Horn sign: Pain caused by gentle traction of right
testicle indicative of appendicitis.
SURGERY FOR INGUINAL HERNIA
ndication
I
Direct/indirect inguinal hernia in adults.
ANESTHESIA
Spinal/general/local anesthesia.
POSITION
Supine.
omplications
C
Immediate
¾ Hemorrhage due to slipping of ligature from
appendicular artery
¾ Cecal perforation
Early
¾ Wound infection/ peritonitis/ septicemia
¾ Pelvic abscess
¾ Paralytic ileus
Late
¾ Intestinal obstruction due to adhesions
¾ Fecal stula
¾ Incisional hernia.
omplications
C
Immediate
¾ Injury to vas deferens
¾ Injury the bowel present in sac
¾ Hemorrhage due to injury to inferior epigastric vessels
Early
¾ Wound sepsis
¾ Osteitis pubis
Late
¾ Recurrence
¾ Nerve entrapment (Ilio-inguinal nerve causing
hyperesthesia over the medial side of inguinal
canal).
116
Section 4: Operative Steps
ey Points
K
Herniotomy: Excision of hernial sac
Herniorrhaphy: Herniotomy + reinforcement of posterior
wall of inguinal oor
Hernioplasty: Herniotomy + tension free mesh repair.
HERNIOTOMY
It involves identication, dissection of hernial sac from
the cord structures, followed by its trans-xation and
excision.
Figure 2: Herniotomy
Chapter 24: Gastrointestinal
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
117
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Incision:
¾ Oblique incision: Given 2 cm above and parallel to
the inguinal ligament over its medial 2/3rd part
¾ Transverse incision (preferred in small children):
Given directly over deep inguinal ring
The incision is deepened to cut the supercial Camper’s
fascia and the deep Scarpa’s fascia to expose external
oblique aponeurosis
The following vessels need ligation if they come in
eld:
¾ Medially: Supercial external pudendal vessels
¾ Laterally: Supercial circumex iliac vessels
The EOA is incised along the line of incision extending
laterally up to deep inguinal ring and medially dividing
the supercial inguinal ring
Ilio-inguinal nerve is identied and retracted laterally to
prevent any injury to it
If hernioplasty is planned then the upper ap of EOA
is dissected upwards to expose conjoint tendon and the
lower ap is dissected to expose the shining inguinal
ligament
The cord is identied, lifted from the fascia transversalis
on index nger
The hernial sac is dissected from the cord using blunt
dissection with the help of plain forceps and nger
The margins of hernial sac are held with hemostatic artery
forceps and injury to vas deferens or testicular vessels is
avoided
The hernial sac is opened with the help of scissors,
contents are examined and reduced into the peritoneal
cavity
Hernial sac is twisted and the neck of the sac is transxed
using suture and the distal part of sac is excised
The cord is placed in its original position and the EOA is
sutured leaving a space equal to the tip of little nger to
form the new supercial inguinal ring
The wound is closed in layers.
ey Points
K
In case of a direct hernial sac, sac may be excised if it
is large or may simply be pushed back followed with
herniorrhaphy.
HERNIORRHAPHY
ethod
M
The steps of herniotomy are followed in the same manner
as described previously.
Types of Tissue Repairs
Lytle’s repair
Plication of fascia transversalis to narrow the DIR in
case of a weak/patulous ring
Bassini’s repair
Fascia transversalis is incised from pubic tubercle
to DIR
Conjoint tendon with fascia transversalis is
approximated with inguinal ligament
Modied Bassini’s repair
Most commonly performed procedure
No splitting of fascia transversalis
Only conjoint tendon is approximated to inguinal
ligament
Shouldice’s repair
Also known as double breasting of inguinal canal
Fascia transversalis is incised from pubic tubercle
to DIR
Repair is done in four layers
1. First layer: Lower flap of fascia transversalis
approximated to lateral border of rectus.
2. Second layer: Upper ap of fascia transversalis
approximated to inguinal ligament.
3. ird layer: Conjoint tendon approximated to
inguinal ligament.
4. Fourth layer: Supercial part of conjoint tendon
approximated to inner part of EOA.
Mc Vay/Lothiessan’s repair/Cooper’s ligament repair
Cooper’s ligament is dissected by dividing the
iliopubic tract
e conjoint tendon is approximated to Cooper’s
ligament medially and to iliopubic tract laterally
Done in some cases of femoral hernia
Darn repair
Conjoint tendon and inguinal ligament are held
together by continuous nylon sutures which form a
mesh like structure in between them
e sutures are kept loose thus providing an articial
mesh like eect.
It involves herniotomy with reinforcement of posterior
wall of inguinal oor along with:
Repair of deep inguinal ring (indirect inguinal hernia)
Repair of fascia transversalis with simple invagination
of sac (direct inguinal hernia).
ey Points
K
Father of modern herniorrhaphy: Eduardo Bassini
Marcy’s repair: Indicated for Gilbert type 2 hernias in
children and young adults.
118
Section 4: Operative Steps
HERNIOPLASTY
It includes herniotomy with strengthening of posterior
wall of inguinal oor by mesh implants.
TYPES
1. Lichtenstein tension free hernioplasty
Most preferred method
Polypropylene mesh is placed over the fascia
transversalis and sutured to:
Conjoint tendon
Inguinal ligament
Pubic tubercle
Lacunar ligament
Figure 3: Mesh hernioplasty
Mnemonic-
Mesh is sutured to
CIPLa structures
2. Preperitoneal repair
Can be done transperitoneally by lower midline
laparotomy or extraperitoneally (without opening
the peritoneum)
A space is created between the peritoneum and the
fascia transversalis and a mesh is kept in this space
3. Stoppa’s Great or Giant Prosthetic Reinforcement of
Visceral Sac (GPRVS)
A large prosthetic mesh is kept between peritoneum
and the whole of abdominal wall to obliterate all
potential hernia sites through a lower midline
abdominal incision
Indicated for bilateral inguinal hernias, very large
hernias, patients with collagen disorders.
Some Important Procedures
A. Kuntz operation (Inguinal orchidectomy)
Spermatic cord along with testis is ligated and
divided at DIR so that DIR can be permanently
closed
Indications
In elderly patients with recurrent hernia
Damage to testicular artery or cord during
herniotomy
B. Transabdominal preperitoneal repair (TAPP)
Pneumoperitoneum created laparoscopically
e peritoneum is separated from fascia transversalis
and a mesh is kept in this space
C. Total extraperitoneal repair (TEP)
Insuation of carbon dioxide is done directly into
preperitoneal space without entering the peritoneal
cavity
e mesh is placed in this space
is procedure is much safer than TAPP approach.
ILEOSTOMY
It is a surgically created communication between the
distal part of small bowel and abdominal wall for various
purposes.
ndications
I
In cases of ileal perforation when:
¾ General condition of patient is low
¾ Unhealthy and inamed ileum
¾ There is an impending perforation distally
As a part of one stage proctocolectomy for ulcerative
colitis
As a diversion route for GI contents in conditions like:
¾ Severe colitis
¾ Necrotising enterocolitis of children
¾ Distal bowel anastomosis
Intestinal obstruction due to advanced and widespread
malignancy.
CLASSIFICATION
Temporary vs Permanent
In temporary stomas, usually the stoma reversal is
done as soon as the acute condition resolves and
general condition of the patient improves.
In permanent stomas, there is no option for stoma
reversal and the patient has to live with stoma
throughout his life.
Loop ileostomy vs End ileostomy vs Double barrel
ileostomy
In loop ileostomy, loop of ileum is surgically brought
through the skin creating a stoma but can be closed
later at a suitable time.
In end ileostomy, only one end of ileum is everted
and sutured to skin.
In double barrel ileostomy, the resected ends of the
ileum are brought out together through the skin.
Chapter 24: Gastrointestinal
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Continent vs Non-continent
Continent ileostomy (Kock pouch) is an alternative
to end ileostomy for patients who have undergone
total proctocolectomy. The pouch created has a
volume of about 500 ml so that faeces can be stored
temporarily.
In non-continent ileostomy, the content pass
spontaneously and continuously from the stoma
without any control.
ANESTHESIA
General anesthesia.
POSITION
Supine.
CHOOSING THE SITE OF ILEOSTOMY
SITING OF ILEOSTOMY
Usually in right iliac fossa equidistant from umbilicus,
ASIS and the fold of groin
Should not be too near to the laparotomy wound
Should be at a site where ileostomy bag can be easily
applied.
ethod
M
Antiseptic dressing and draping of the operative eld is
done
The operative procedure (according to indication) prior to
ileostomy is completed and the fashioning of ileostomy is
done in the following manner
The ileostomy aperture (circular disc) of about 2–
3 cm diameter is cut at the chosen ileostomy site and the
tissues are dissected to reach the EOA or anterior rectus
sheath which is then incised in a cruciate (‘+’ shaped)
fashion
The muscle (IO + TA) below it are split to reach the
peritoneum which is then cut and dilated with ngers to
enter inside the peritoneal cavity
The terminal ileum is drawn through the aperture so
that about 5 cm of it projects above the skin surface
The protruding ileum is anchored to the cut margins of
EOA by a few stitches
The protruding surface of ileum is then incised along
the axis of mesentery
The protruding ileum is turned back upon itself by
a row of stitches which pick up the cut edge of ileum,
then the serosa of the buried ileum followed by the skin
margin to fashion a oral shaped ileostomy
The skin around the ileostomy is dried and the patency of
the ileal loops is rechecked
Abdominal wound is closed in layers and an appropriate
size bag is xed to the ileostomy site.
119
Figure 4: Siting of ileostomy
POSTOPERATIVE MANAGEMENT
Accurate tting of the ileostomy bag
Application of skin barrier cream to prevent spillage of
contents
Avoid food which upsets the stoma
Such diet is preferred which aids in solidication of
stool, e.g. banana.
omplications
C
Dehydration and electrolyte imbalance
Excoriation of skin
Para-stomal irritation/ ulceration
Ileostomy obstruction
Stoma necrosis/ stenosis (requires revision of ileostomy)
Recession/ prolapse of ileostomy
Post ileostomy diarrhoea
120
Section 4: Operative Steps
1. 2.
3.
Figure 5: Procedure of ileostomy
ey Points
K
Prevention of peristomal skin excoriation
¾ Use drugs which make stool more solid
¾ Keep the peristomal skin dry
¾ Use of barrier creams, e.g. Siloderm (contains dimethicone, zinc oxide, etc.)
¾ Application of natural products like raw egg white to form barrier over the skin
Dierence between ileostomy and colostomy
Ileostomy Colostomy
Stoma Ileum used for stoma Colon used for stoma
Stoma diameter Less More
Site Usually on the right side of the abdomen Usually on the left side of the abdomen
Fashioning of stoma Protrudes about 2–3 cm above the skin surface to
discharge the eux directly into the bag
Consistency of eux More liquid More solid
Parastomal excoriation/
ulceration
Electrolyte imbalance More common Less common
Common Rare
Colon edge directly stitched to the skin
surface without everting it
Chapter 24: Gastrointestinal
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
121
COLOSTOMY
It is a surgically created communication between the colon
and abdominal wall for various purposes.
ndication
I
In cases of colonic perforation when:
¾ General condition of patient is low
¾ Unhealthy and inamed ileum
¾ There is an impending perforation distally
As a diversion route for GI contents in conditions like
¾ Severe colitis
¾ Necrotizing enterocolitis of children
¾ Distal bowel anastomosis
¾ Hirschsprung’s disease
Intestinal obstruction due to colon carcinoma
In neonates for imperforate anus (Anorectal malformation)
After major surgeries like Abdominoperineal resection
As a part of Hartman’s procedure.
CLASSIFICATION
Same as that of ileostomy.
ANESTHESIA
General anesthesia.
POSITION
Supine.
CHOOSING THE SITE OF COLOSTOMY
S
ITING OF COLOSTOMY
Conventionally on left side of anterior abdominal wall
equidistant from umbilicus, ASIS and the fold of groin
Figure 6: Colostomy
122
Section 4: Operative Steps
In transverse colostomy: In right upper abdomen
midway between umbilicus and costal margin and
placed over rectus muscle but extending just lateral to
its lateral border.
ethod
M
Similar to ileostomy with following dierences:
No projection above skin surface required in colostomy as
the contents are mostly solid
In transverse colostomy, after excising anterior rectus
sheath, rectus abdominis muscle is encountered in place
of IO+TA.
COMPLICATIONS AND POSTOPERATIVE
MANAGEMENT
Same as in Ileostomy.
ey Points
K
See the dierences between ileostomy and colostomy in
previous topic.
ILEOSTOMY/COLOSTOMY CLOSURE
ndication
I
When the purpose of forming a stoma has been achieved
and the stoma is no longer required.
ANESTHESIA
Spinal anesthesia/General anesthesia.
POSITION
Supine.
ethods
M
Prior to surgery the distal bowel should be assessed by
either a distal loopogram or colonoscopy to check the
patency of the bowel up to rectum
Antiseptic dressing and draping of the operative eld is
done
Mobilization of ileostomy/colostomy is done by giving
an elliptical incision on the skin around the stoma site and
dissection is done up to the peritoneum
Margins of the ileum/colon are freshened using scissors
Anastomosis of ileum or colon is done by various
techniques depending upon surgeon to surgeon
Bowel is placed back in peritoneal cavity and a drain is
placed
Abdominal wound is closed in layers.
Intraperitoneal closure: Ileostomy/Colostomy
is mobilized by separating it from all the layers of
abdominal wall including peritoneum and is placed back
in peritoneal cavity after closure
Extraperitoneal closure: Ileostomy/Colostomy is not
separated from all the layers of abdominal wall and is
closed in subcutaneous plane after dening the margins
of colostomy.
A
B
Figure 7: Ileostomy/colostomy closure
omplications
C
Leak of ileostomy/colostomy closure
Fecal stula
Peritonitis.
FEEDING JEJUNOSTOMY
It is a surgically created communication between the
proximal jejunum and abdominal wall for the purpose of
feeding.
ndications
I
After repair of duodenal injuries
Gastric outlet obstruction
In carcinoma/stricture esophagus to start enteral feeding
Severe gastroesophageal disease.
Соседние файлы в папке @xirurgi_2025