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Chapter 27: Urology
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POSITION
Lithotomy.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Preliminary cystoscopy is done to access the size of
prostate, inspect ureteric orices, bladder wall and
trigone
Bladder is lled with 150ml of irrigating solution and
the resection of prostate is done in the following order
with the help of a resectoscope-
¾ Resection at bladder neck and median lobe
¾ Resection of lateral lobes distally up to verumontanum
¾ Resection of the remaining prostatic tissue in oor,
apex and near verumontanum
Hemostasis is achieved by electro-coagulation of the
bleeding vessels
A 24 Fr Triway Foley catheter is inserted in the bladder
and the balloon is inated
Transient traction may be applied to provide tamponade
eect at prostatic fossa to achieve hemostasis
Continuous irrigation with normal saline is started till the
time urine becomes clear.
omplications
C
Early
¾ Bleeding
¾ Extravasation or perforation of prostatic capsule
¾ Transurethral syndrome – Due to excessive
absorption of irrigating uid leading to hyponatremia
Late
¾ Recurrence of symptoms (due to inadequate
resection)
¾ Urethral stricture
¾ Urinary incontinence
¾ UTI
SUPRAPUBIC CYSTOLITHOTOMY
It is the removal of urinary bladder stone by suprapubic
approach.
ndication
I
Bladder stone.
Figure 5: Suprapubic cystolithotomy
ethods
M
Antiseptic dressing and draping of the operative eld is
done
A bladder lump is made by lling saline in it with the
help of drip set and Foley catheter
A transverse suprapubic Pfannenstiel incision about 2
nger breadths above pubic symphysis is preferred
Incision is deepened through subcutaneous tissues to
reach rectus sheath which is then incised longitudinally to
reach rectus abdominis muscle
Muscle is split and retracted laterally with the help of
Langenbach’s retractors to visualize bladder
Peritoneal covering is stripped o from the bladder using
a peanut swab.
Bladder is opened vertically between two stay sutures
and the stones are identied by palpating them with
index nger
The stones are removed with the help of cystolithotomy
forceps and the bladder is closed in two layers
A peri-vesical drain is placed and a Foley catheter is
inserted per-urethrally
The abdominal incision is closed in layers
omplications
C
Postoperative urine leak (in perivesical drain)
Hematuria.
SUPRAPUBIC CYSTOSTOMY
It is a surgically created communication between urinary
bladder and the lower part of anterior abdominal wall.
143
ANESTHESIA
Spinal anesthesia.
POSITION
Supine.
ndication
I
Traumatic urethral rupture
Urethral cancer
Congenital defects of urinary tract
In postoperative cases of TURP, cystolithotomy, etc.
Requirement for long-term urinary diversion (e.g.
neurogenic bladder).
144
ontraindications
C
ANESTHESIA
Local anesthesia.
Section 4: Operative Steps
Figure 6: Suprapubic cystostomy
Coagulopathy
Previous lower abdominal or pelvic surgery (because of
the possibility of adhesions between the bowel and the
bladder)
Pelvic cancer, with or without a history of irradiation
(because of the possibility of adhesions)
Placement of orthopedic hardware for pelvic fracture
repair.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
A bladder lump is made by lling saline in it with the
help of drip set and Foley catheter
A small transverse suprapubic incision is given about 2
nger breadths above pubic symphysis
Incision is deepened through subcutaneous tissues to
reach rectus sheath which is then incised longitudinally to
reach rectus abdominis muscle
Muscle is split and retracted laterally with the help of
Langenbach’s retractors to visualize bladder
A syringe is used to aspirate urine to conrm position of
bladder
A suprapubic trocar with cannula is inserted in bladder
and trocar is removed so that of urine comes out through
it
A Foley catheter is inserted quickly through the tunnel of
cannula and the balloon is inated
Skin incision is closed and sterile dressing is done.
omplications
C
Intra-abdominal visceral organ injuries
Blockage of catheter
UTI
Hematuria
Urinary stula.
ey Points
POSITION
Supine.
K
Also known as Vesicostomy.
SURGERY FOR HYDROCELE
Hydrocele refers to the accumulation of serous uid in layers of tunica vaginalis around the testis.
ndications
I
Indication for surgery in hydrocele include:
Large size interfering with day-to-day activities
Symptomatic
Cosmetic reasons
Medically unt for a job
Causing infertility.
TECHNIQUES
Surgery
Eversion of sac (Jaboulay’s procedure)
Plication of sac (Lord’s plication)
Hydrocelectomy or subtotal excision of parietal layer
of tunica vaginalis
Non-surgical options
Aspiration and sclerotherapy.
ANESTHESIA
Local anesthesia
Spinal anesthesia.
POSITION
Supine.
Chapter 27: Urology
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Figure 7: Surgery for hydrocele
145
A. JABOULAY’S PROCEDURE
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Skin and subcutaneous tissue is inltrated along the line
of incision along with a cord block.
Assistant holds the scrotum to stretch the skin
A vertical incision is given over the swelling to incise the
skin and dartos muscle
External and internal spermatic fascia are incised to
expose the parietal layer of tunica vaginalis
Blunt dissection using ngers is done between this
parietal layer and other layers of scrotum to deliver the
sac out of scrotum
A stab incision is given on the anterior layer of tunica
vaginalis and the serous uid is aspirated
The incision over tunica is extended both upwards and
downwards and the margins are turned around the cord
structures
The margins of sac are stitched posteriorly leaving one
nger breadth space at the end to prevent compression
of cord structures
A corrugated drain is placed below the dartos
muscle and taken out through a separate skin
incision to drain any postoperative blood or serous
collection
The testis is placed in its original position and the
scrotum is stitched in two layers
Coconut scrotal dressing is applied for compression and
hemostasis.
B. LORD’S PLICATION
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Skin and subcutaneous tissue is inltrated along the line
of incision along with a cord block
Assistant holds the scrotum to stretch the skin
A vertical incision is given over the swelling to incise the
skin and dartos muscle
External and internal spermatic fascia are incised to
expose the parietal layer of tunica vaginalis
other layers of scrotum and after aspiration of uid,
testis is delivered outside the scrotum
Cut margins of the sac are plicated by a series of
interrupted absorbable sutures and when these sutures
are tied, sac with gather to form a Lillie ru at the
periphery of testis
The plication sutures run from the cut edge of tunica
upwards to the mediastinum testis.
Testis with its plicated sac is gently squeezed back into
scrotum and the incision is closed in two layers
omplications
C
Hematoma formation
Wound infection
Pyocele
Recurrence (rare)
146
Section 4: Operative Steps
ey Points
K
Disadvantages of sclerotherapy
¾ Recurrence
¾ Chances of infection
¾ Painful
¾ Formation of cysts
Inguinal approach preferred in children with congenital
hydrocele
Treatment of choice for congenital hydrocele is herniotomy.
CIRCUMCISION
It is the excision of the preputial foreskin to expose the
glans penis.
ndications
I
For religious reasons in muslims and jews
Phimosis
Paraphimosis
Recurrent balanitis
Prior to radiotherapy for carcinoma penis.
ethods
M
Antiseptic dressing and draping of the operative eld is done
Adhesions between prepuce and glans are separated by
curved mosquito artery forceps
The tip of the prepuce is grasped by 3 mosquito artery
forceps at 3 o’clock, 6 o’clock and 9 o’clock position
A dorsal cut is made in the prepuce at 12 o’clock position
extending proximally up to 5 mm of corona glandis
Circumferential incision is taken in the penile skin at the
level of corona glandis towards the frenulum
A mosquito artery forcep is applied at the frenulum and the
prepuce is divided distal to it
A “gure of 8” stitch with chromic catgut is applied at the
frenulum to control bleeding from frenular artery
The cut margins of the prepuce are stitched to the corona
Sterile dressing is applied leaving the urinary meatus exposed.
omplications
C
Bleeding from frenular artery
Wound infection
Removal of excessive preputial skin (can lead to bending
or bowing of the penis)
Injury to glans penis
Injury to urethral meatus (can lead to urethral stricture).
ANESTHESIA
General anesthesia in pediatric patients
Penile ring block (local anesthesia) in adults.
POSITION
Supine.
K
ey Points
Figure 8: Circumcision
6 o’clock position is located inferiorly at the midline raphe
where frenulum is attached
Monopolar diathermy avoided due to chances of
coagulation of the body of penis
Local anesthesia with adrenaline is contraindicated as it
can cause gangrene of penis.
Chapter 27: Urology
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147
VASECTOMY
It is a method of male contraception with division of vas
deferens.
TECHNIQUES
Convention incision technique
No scalpel vasectomy (NSV).
ndication
I
Family planning.
NO SCALPEL VASECTOMY
ANESTHESIA
Local anesthesia.
POSITION
Supine.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Vas is isolated using three ngers
¾ Middle nger and thumb to hold the vas
¾ Index nger to stretch the skin
The vas is brought at the junction of upper 1/3rd and
lower 2/3rd of anterior scrotal raphe and xed with a
ringed clamp
Local anesthetic agent is inltrated here
The vas dissecting forceps is inserted into the lumen
of vas and gradually opened to separate the overlying
layers until vas is visualized
The vas is grasped between the blades of vas dissecting
forceps and is delivered out of the wound
The ends of the vas are ligated and a small piece of vas
is removed and sent for histopathology
The cut ends of the vas are electrocauterized to
prevent recanalization and are deposited back
Antiseptic dressing is applied on the wound.
omplications
C
Hematoma
Sperm granuloma
Wound infection
Recanalization of vas
Hematocele/pyocele.
Figure 9: No scalpel vasectomy
148
FOLEY CATHETERIZATION
ndications
I
Acute/chronic retention of urine
To monitor urine output
In immobilized/postsurgical patients
After urinary tract surgeries.
ontraindications
C
Blood at meatus
Pelvic fractures (Relative contraindication)
Urethral strictures.
Section 4: Operative Steps
POSITION
Patient supine with legs apart.
ethods
M
Antiseptic dressing and draping of the genitalia is done
Foreskin is retracted and the glans penis is cleaned with
antiseptic solution
2% Lignocaine jelly is inserted through external urethral
meatus
After waiting for ve minutes, penis is held vertically
upwards to straighten the penile urethra
Foley catheter is inserted in the meatus till the urine
comes out of it
Catheter is advanced a little further and 15 to 20 mL of
distilled water is introduced through the side channel of
catheter (varies for dierent sizes)
Catheter is pulled outwards to check if the balloon is
properly inated
The catheter is then connected to a Urobag
The preputial skin is brought back over the glans penis to
prevent the development of paraphimosis.
Figure 10: Foley catheter
IN FEMALES
done
Labia majora is retracted with ngers of left hand till the
urethral orice is seen
2% Lignocaine jelly is inserted through external urethral
orice
Foley catheter is inserted in the meatus till the urine
comes out of it
Rest procedure is similar as that in males.
omplications
C
Bleeding
Urethral injury
Infection
Paraphimosis (If foreskin left retracted for a long time)
Urethral stricture.
Miscellaneous
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EXCISION OF LIPOMA
Chapter
28
ANESTHESIA
Local anesthesia.
POSITION
Depends on the position of the lipoma.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
An elliptical incision is given over the lipoma along the
Langer’s lines of the body
Incision is deepened through subcutaneous tissue and
skin aps are raised
Lipoma is dissected from surrounding tissues by ne
dissecting scissors or by nger dissection
Hemostasis is achieved
Excised lipoma is sent for histopathological examination
and skin is closed.
omplications
C
Recurrence
Wound infection
Hematoma/Seroma
Injury to nerves and vessels.
Figure 1: Excision of lipoma
EXCISION OF SEBACEOUS CYST
ANESTHESIA
Local anesthesia.
POSITION
Depends on the position of the cyst.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
An elliptical incision is given over the cyst along the
Langer’s lines of the body with center being the punctum
of the cyst
150
Incision is deepened through subcutaneous tissue and
sebaceous cyst is dissected from surrounding tissues by
ne dissecting scissors
Excised sebaceous cyst is sent for histopathological
examination and skin is closed.
omplications
C
Recurrence (If cyst wall is not excised properly)
Wound infection
Hematoma
Injury to nerves and vessels.
Section 4: Operative Steps
LYMPH NODE BIOPSY
Excision of a single lymph node or a group of lymph nodes.
ndications
I
Suspicion of disease involving lymph nodes, e.g.
Tuberculosis
Metastasis of cancer to lymph nodes
Isolated or generalized lymphadenopathy.
ANESTHESIA
Local anesthesia.
Figure 2: Lymph node biopsy
POSITION
According to the site of LN.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Skin incision preferred along the Langer’s lines of the
body
Incision is deepened through subcutaneous tissue and
lymph node is dissected from surrounding tissues by ne
dissecting scissors
Excised LN is sent for histopathology and skin is closed.
omplications
C
Wound infection
Hematoma
Injury to nerves and vessels.
Index
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A
Abdomen anteroposterior view, X-ray 70
Abdominal
drain kit 47
viscera trauma 49
wall reinforcement 64
Abscess 125
dierent types of 102
drainage 101
formation 108
Acalculous cholecystitis 129
Achalasia cardia 76, 77
Acidic urine 82
Acrocyanosis 104
Acute paronychia 102
Adhesive bandage 66
Air bubble 80
Allan Park’s operation 125
Allis tissue forceps 10
Allison’s retractor 22
Anal atresia 91
Anal ssure, surgery for 126
Anal stula, surgery for 127
Anorectal
abscess 102
anomaly 91
Antegrade method of cholecystectomy
129
Appendicectomy 114
Aseptic suction 113
Auchincloss modication 134
Autoclaving 3
Axillary
abscess 103
dissection 135
vein 135
B
Babcock tissue forceps 11
Backhaus towel (corner) clip 8
Bags 55
Balfour’s retractor 23
Bandages and adhesive tapes
cotton 65
crepe 65
elastic adhesive 66
Hipore surgical type 66
Bard Parker knife handle 8
Barium enema
contraindication 78
indication 78
types 78
air contrast study 78
double contrast 78
single contrast study 78
Barium meal 76
Barium swallow 76
Barron’s banding 125
Bassini’s repair, modied 117
Bell’s nerve 135
Bent inner tube appearance 75
Bilateral renal calculi 81
Biliary ducts 79
Bird’s beak appearance 75
Bladder lump 141
Bleeding 110
disorders 106
from vessels 100
Blood transfusion set 53
Bone cutter 31
Bowel
anastomosis 60
obstruction 76
perforation 76
Breach of peritoneum 105
Breast
abscess 102
tissue 135
Bronchopneumonia 100
Buerger’s disease 104
Buttery cannula 54
C
Caecal volvulus 75
Calcaneum bone, level of 95
Calcied
bladder polyp 84
lymph nodes 84
Calcium oxalate stones 82
Calot’s triangle 130
proceeding 129
Cannon ball metastases, dierential
diagnosis 89
Cannula 32
Capsule of broadenoma 136
Carcinoma
esophagus 77
upper airway tract 112
Catch lock 7
Catgut
chromic 60
plain 60
Catheter wings 62
Cattle’s intestine, serosa of 60
Cellulitis 100
Central venous
catheter 39
line 106
Cephalic vein 135
Cervical collar incision 111
Chagas disease 77
Cheatle’s forcep 6
Chest
cavity 57
complications 100
wall, operative steps 134
X-rays 89
Chilaiditi’s sign 72
Cholangitis 129
Cholecystectomy 7
Choledocho-duodenostomy anastomosis
43
Choledocholithiasis 129
Choledocholithotomy 18
Chronic immunosuppression 129
Chronic parotitis 109
Cidex 3
Circular disc 119
Circumcision
anesthesia 146
indications 146
position 146
Closure of skin incision 60
Coat of savlon 99
Coconut scrotal dressing 145
Coee bean 75
Coin-gas shadow 92
152
A Practical Guide to Surgical Instruments, X-rays and Operative Interventions
Colon 76
Colonic
gas shadows 73
pseudo-obstruction 75
Color coding 37, 42
Colostomy 94
anesthesia 121
choosing the site of 121
classication 121
closure 122
complications and postoperative
management 122
indication 121
position 121
Condom catheter 36
Conjoint tendon 118
Cooper’s ligament repair 117
Corrugated drain 145
Corrugated rubber drain 50
Cotton bandage 65
Crepe bandage 65
Cricopharynx 75
Cupola sign 72
Cut capsular edges 142
Cystine stones 82
Cystogram phase 86
Cystolith 84
Cystolithotomy forceps 17
Czerney’s retractor 20
D
Dahl Froment’s sign 75
Darn repair 117
Deaver’s retractor 21
Deep cervical fascia 111
Deep vein thrombosis 100
Deep venous thrombosis 106
Descending urethrography 88
Desjardin’s choledocholithotomy
forceps 18
Desjardin’s forceps 131
Diuse esophageal spasm 77
Digital skiagram
abdomen AP view 72
chest P-A view 71
Digital X-ray 69
Dilated contrast lled posterior
urethra 88
Disinfection 3
Dissect lumbar sympathetic
chain 25, 105
Distal bowel anastomosis 121
Distal loopogram
indications 94
method 94
Diverticula 76
Domes diaphragm 70
Double
barrel ileostomy 118
breasting of inguinal canal 117
hook skin retractor 23
Doyen’s
gastrointestinal clamp 28
retractor 22
towel clip, uses 8
Drainage uid 57
Drains 47
Drip chamber 52
Drip sets 51
Duodenal stula 131
Duodenostomy 56
Duodenum 105
delineated 79
E
Elastic adhesive bandage 66
Emphysematous cholecystitis 129
Empyema thoracis 49, 90, 137
End ileostomy 118
Endorectal advancement ap, indications
128
Esophageal
malignancy 77
sphincter fails 77
stricture 77
Esophagus 77
Ethilon 60
Excision of lipoma
anesthesia 149
complications 149
methods 149
position 149
Excision of sebaceous cyst
anesthesia 149
complications 150
methods 149
position 149
Exploration of common bile duct 131
External jugular vein 110
F
Facial nerve 110
Faecoliths 82
Farabeuf’s respirator 31
Fasciovenous plane of Patey 110
Fecal incontinence 126
Feeding jejunostomy
anesthesia 123
bag 56
indications 122
position 123
types of 123
Fever 100
Fibroadenoma 48, 136
capsule of 136
enucleation 136
Fibrous stricture 73
Filaments 58
Finger dilatation of anus 126
Firearm injury 95
Fissure formation 125
Fissurectomy 126
Fistula 92
formation 125
in-ano 93
Fistulectomy 127
Fistulogram 92
Fistulotomy 127
Flail chest 90
Flatus tube 44
Fluid lter 52
Foley balloon catheter, uses of 35
Foley catheter 55, 88, 144, 148
complications 148
contraindications 148
in females 148
indications 148
methods 148
position 148
Football sign 72
Forceps 10-16
Allis tissue forceps, uses 10
Babcock forceps, uses 11
hemostatic artery forceps, uses 12
Kocher forceps, uses 11
Lahey’ forceps, uses 16
Lane’s tissue forceps, uses 14
lister sinus forceps, uses 15
plain forceps, uses 13
Russian forceps, uses 14
toothed forceps, uses 13
Vas holding forceps, uses 16
Foreign body 73
in larynx 112
X-rays 95
Formaldehyde 3
Frey’s syndrome 110
Frost bite 104
Fumigation 3
G
Gall stones 73
Gallbladder dyskinesia 129
Gallstone pancreatitis 129
Ganglionic cells 77
Garrotte mark 111
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