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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_848_Библиотеки_им_академика_М_И_Перельмана
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Figure 3: Procedure of laparoscopic cholecystectomy
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ey Points
K
Methods to check the correct position of veress needle:
¾ Inject 5 ml normal saline through veress needle. If the saline goes inside without any resistance and no uid comes back on re-
aspiration, then veress needle is in right position
¾ A drop of saline is placed on veress needle and abdominal wall is lifted up. The drop of saline will be sucked in due to negative
pressure.
Chapter 25: Hepatobiliary
133
Chest Wall
Chapter
26
MODIFIED RADICAL MASTECTOMY
Modied radical mastectomy (MRM) involves removal of:
Whole breast
Nipple-Areola complex
Fascia over pectoralis major
Skin around the tumor with 1 cm margin
Axillary lymph node clearance (Level I, II nodes).
MODIFICATIONS
1. Patey’s Type
Pectoralis minor also removed for proper clearance of
level III axillary lymph node (LN).
2. Scanlon’s Modication
Pectoralis minor detached at tip of coracoid process to
facilitate removal of level III lymph nodes.
3. Auchincloss Modication
No removal/detachment of pectoralis minor muscle
No clearance of level 3 LN
Preservation of medial pectoral nerve.
ndications
I
Breast cancer depending upon stage:
In locally advanced breast cancer (Stage IIIa,b,c)
along with neoadjuvant chemotherapy and adjuvant
radiotherapy
In some cases of early invasive breast cancer (Stage I, IIa,
IIb) especially when axillary lymph nodes are found to
be involved after sentinel lymph node assessment.
ANESTHESIA
General anesthesia.
Figure 1: Modied radical mastectomy
POSITION
Supine with rolled sheath under the side of hemithorax
to be operated
Patient on the edge of table with ipsilateral arm
abducted to 90° resting on an arm rest.
Chapter 26: Chest Wall
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ethods
M
Antiseptic dressing and draping of the operative eld is done
Skin incision
¾ For central subareolar tumor
Stewart incision: Elliptical incision including Nipple-areola complex with 2 cm margin from ipsilateral sternal margin to anterior
border of Latissimus dorsi
¾ For upper quadrant tumor
Oblique elliptical incision from xiphisternum towards ipsilateral axilla
¾ For inner quadrant tumor
Modied Stewart incision so that medial extent of incision extends up to midsternum
Skin aps of 7–8 mm thickness are raised using electrocautery or knife up to:
¾ Superiorly – Clavicle
¾ Inferiorly – Costal margin
¾ Medially – Mid of sternum
¾ Laterally – Anterior border of Latissimus dorsi
Breast tissue is raised along with pectoral fascia and dissection is carried out till lateral border of Pectoralis major muscle
Fascia over the Pectoralis muscle is incised to enter the axilla
Axillary dissection is done which includes:
¾ Stripping of bro-fatty tissue
¾ Dissection of Pectoralis minor muscle
¾ Clearance of Level I, II lymph nodes
Hemostasis is achieved and a suction drain is placed with its one arm in axilla and one between the skin aps and muscle
Incision is closed in layers and compressive dressing is done.
135
omplications
C
Early
¾ Haemorrhage due to injury to vascular structures like axillary vein and artery
¾ Injury to nerves that are to be preserved in MRM
¾ Seroma/Hematoma beneath the skin aps
¾ Skin ap necrosis
¾ Wound dehiscence
Late
¾ Lymphedema – 10% cases
¾ Local tumor recurrence
¾ Late metastatic disease
ey Points
K
Structures preserved during Patey’s MRM
¾ Axillary vein
¾ Bell’s Nerve (Long thoracic nerve/Nerve to Serratus anterior) – Injury causes winging of scapula
¾ Cephalic vein
¾ Thoracodorsal nerve (Nerve to Latissimus dorsi): Injur y causes weakened internal rotation and abduction
of shoulder
The aps of skin if too thin can cause skin necrosis and if too thick can have residual malignant cells
Level of Axillary LN
¾ Level I – Lateral to Pectoralis minor muscle
¾ Level II – Behind Pectoralis minor muscle
¾ Level III - Medial to Pectoralis minor muscle
Axillary vein is the upper limit of axillary dissection
Other types of mastectomy
¾ Simple Mastectomy – Whole breast + N-A complex + 1 cm skin margin
¾ Extended Simple Mastectomy – Simple mastectomy + Level I LN
¾ Halsted Radical Mastectomy – Patey’s MRM structures + Pectoralis major muscle
¾ Extended Radical Mastectomy – Patey’s MRM structures + Internal mammary LN
¾ Super Radical Mastectomy - Patey’s MRM structures + Internal mammary LN + Mediastinal LN + Supraclavicular LN
Mnemonic:
ABCD structures
are preserved in
Patey’s MRM
Mnemonic:
‘I’ resembles ‘L’
‘III’ resembles ‘M’
136
Section 4: Operative Steps
FIBROADENOMA ENUCLEATION
Fibroadenoma is one of the benign tumors of breast.
Figure 2: Fibroadenoma enucleation
ndication
I
Fibroadenoma.
ANESTHESIA
Local anesthesia
General anesthesia.
POSITION
Supine.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Incision
¾ If the broadenoma is near to N-A complex - Circum-
ferential incision is preferred at the junction of areola
and skin (better cosmesis)
¾ If the broadenoma is far from N-A complex – Radial
incision over the swelling (prevent injury of ducts)
Incision is deepened to reach the capsule of broadenoma
The capsule of broadenoma is held with the help of
Allis forceps and dissection is done with the help of artery
forceps to free it from surrounding tissues
The broadenoma is removed and hemostasis is achieved
A small suction may be placed in cavity if a large bro-
adenoma is excised
Incision is closed in two layers and compressive dressing
is done.
omplications
C
Recurrence
Hematoma/Seroma formation
Wound dehiscence
Incomplete excision of broadenoma.
INTERCOSTAL DRAIN PLACEMENT
It is the insertion of a chest drain into the pleural cavity through the intercostal space.
Figure 3: Chest tube insertion
Chapter 26: Chest Wall
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137
ndications
I
Empyema thoracis
Pneumothorax
Hemothorax
Pleural eusion
Following thoracotomy for postoperative drainage.
ANESTHESIA
Local anesthesia.
POSITION
Supine with back rest elevation of about 45°.
Some prefer sitting position with hands resting on a
chair kept on the bed in front of patient.
SITE FOR ICD INSERTION
Most ICD insertion are preferred through the triangle
of safety just anterior to midaxillary line as described
in key points
Earlier some surgeons preferred:
For Hemothorax – 7th or 8th ICS in midaxillary line
For Pneumothorax – 2nd ICS in anterior axillary line.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
A small incision is given with Blade No. 11 on the selected
site
Intercostal muscles are split and separated with the
help of long curved hemostatic forceps to reach parietal
pleura
Chest tube held with a long artery forceps and is pushed
through the parietal pleura to enter pleural cavity
A chest tube with a metallic trocar may also be used at
this stage
The tube is clamped with an artery forceps and
connected to an under-water seal drainage bag and the
other end is xed to skin with the help of silk sutures
The tube is then checked for the movement of water
column to conrm its position in the pleural cavity
Sterile dressing is done and a Chest X-ray is advised to
conrm the position of drain.
omplications
C
Injury to intercostal nerves and vessels
Injury to lung or bronchial vessels
Infection
Kinking/Displacement of tube
Figure 4: Position of intercostal drain placement
138
Section 4: Operative Steps
ey Points
K
Triangle of safety – Bounded by
Inferiorly Superior border of 5th rib
Superomedially Posterior border of Pectoralis major
Superolaterally Anterior border of Latissimus dorsi muscle
Superior border of the rib is preferred for ICD insertion as it does not have any neurovascular structures
The direction of Chest tube insertion:
¾ In hemothorax – Downwards and posteriorly
¾ In Pneumothorax – Upwards and posteriorly.
Figure 5: Triangle of safety
Urology
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Chapter
27
NEPHRECTOMY
ndication
I
Renal tumors
Renal infections:
¾ Pyonephrosis
¾ Chronic pyelonephritis
Gross hydronephrosis with non-functional kidney
Renal injury with avulsion of renal pedicle
Nephrectomy of donor for renal transplant.
ANESTHESIA
General anesthesia.
POSITION
Kidney Position for left sided nephrectomy
Right lateral position
Upper arm supported on arm rest
Right lower limb exed at hip and knee
Left lower limb extended
A pillow kept between both legs
Sand bag/Kidney bridge under the loin to open up space
between costal margin and iliac crest
Table broken down 30°–40° below horizontal level at
leg end
Strapping done at level of shoulders and iliac crest to
stabilize the patient.
Figure 1: Position of nephrectomy
140
ethods
M
Antiseptic dressing and draping of the operative eld is
done
Incision
¾ Subcostal incision starts at angle between 12th rib
and lateral border of erector spinae muscle
¾ Extends to a point 2 cm above and anterior to ASIS up
to lateral border of rectus sheath
Incision is deepened to reach the following muscles
which are then divided
Anterior part
of incision
Supercial EOA Latissimus dorsi
Deep IO Serratus posterior inferior
Posterior part of
incision
Thoracolumbar fascia is incised backward up to the
lateral border of erector spinae muscle preventing any
injury to subcostal nerve and vessels
Blunt dissection is used to separate parietal peritoneum
from deep surface of transversus muscle
Transversus abdominis muscle is divided to expose the
perinephric space
The perirenal fascia (Gerota fascia) is incised between
two artery forceps with the help of scissors to expose pale
yellow perinephric fat beneath which lies the kidney
Kidney is mobilized using blunt finger dissection and
following structures are identified at hilum of kidney
Anteriorly Middle Posteriorly
Renal vein Renal artery Ureter
Three ligatures are passed each around renal vein and
artery using right angled forceps. First renal artery is
ligated with two ligatures proximally and one distally and
divided between them
Similarly, vein is also divided between two ligatures
towards IVC side. Finally, ureter is ligated and divided
Kidney is removed, hemostasis is achieved and a drain is
kept in renal fossa to monitor any postoperative bleeding
Incision is closed in layers and sterile dressing is done.
omplications
C
Early
¾ Hemorrhage due to slippage of ligature from renal
pedicle
¾ Injury to IVC
¾ Accidental opening of peritoneum
¾ Wound infection
Late
¾ Deep vein thrombosis
¾ Incisional hernia
¾ Tumor recurrence in case of renal carcinoma.
ey Points
K
Renal artery is ligated before the renal vein to avoid
venous congestion in kidney.
Section 4: Operative Steps
PROSTATECTOMY
It refers to removal of prostate gland by various methods.
TECHNIQUES
Open Prostatectomy
Young’s perineal approach (obsolete now)
Suprapubic transvesical (Frayer’s) approach
Retropubic (Millin’s) approach
TURP (Transurethral resection of prostate).
OPEN PROSTATECTOMY
ndications
I
Open procedure is preferred over TURP in prostate pathology
only when it is associated with:
Huge prostate with estimated weight > 100 gm
Cardiac conditions (Risk of uid overload in TURP)
Hip joint pathology (Lithotomy position cannot be made)
Known coagulopathy
If any other open urological surgery needs to be done
simultaneously, e.g. Bladder diverticulum, Large bladder
stone.
Figure 2: Procedure of nephrectomy
Chapter 27: Urology
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141
ontraindications
C
Small brous prostate
Suspicion of malignancy
Patient unt for anesthesia
History of previous pelvic surgeries.
dvantages over TURP
A
Low recurrence rate
Complete removal of prostate gland
Less chances of complications like urethral injury/
stricture.
isadvantages over TURP
D
Longer hospital stay
Increased postoperative pain
Long abdominal incision
Increased chances of bleeding.
A. SUPRAPUBIC TRANSVESICAL
STATECTOMY
PRO
It is the enucleation of prostate gland by opening the
anterior wall of bladder.
ANESTHESIA
Spinal anesthesia
Epidural anesthesia.
POSITION
Supine with mild trendelenburg position.
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 finger 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 interior of the bladder is explored for any
pathology
Mucosa over the bladder neck near the internal urethral
opening is incised using a blade or electrocautery
Enucleation of the enlarged lobes of prostate is done
by nger dissection separating it from peripheral normal
compressed prostatic tissue up to the bladder neck. Both
enucleated lobes are separated from bladder neck by
sharp dissection
Hemostasis is achieved by packing the prostatic fossa
with a roller bandage and compressing it for about 10
minutes
A Triway Foley catheter is inserted whose inated bulb is
placed in the prostatic fossa to provide tamponade eect
The anterior wall of bladder is closed in two layers with
help of vicryl sutures and a peri-vesical drain is placed
Incision is closed in layers and continuous irrigation
with normal saline is started till the time urine becomes
clear.
omplications
C
Early
¾ Post-operative clot retention
¾ UTI
¾ Suprapubic urinary stula
Late
¾ Urethral stricture
¾ Urinary incontinence
¾ Recurrence of prostatic symptoms.
ey Points
K
Postoperative management
¾ 1st day – Continuous irrigation
¾ 3rd day – Remove drain if output < 50 mL
Figure 3: Suprapubic transvesical prostatectomy
¾ 5th day – Catheter removed if no bleeding.
142
Section 4: Operative Steps
B. RETROPUBIC PROSTATECTOMY
MILLIN’S OPERATION
It is the removal of prostate gland through a retropubic
approach without incising the bladder.
ndication
I
Same as mentioned in suprapubic transvesical prostatectomy.
ontraindication
C
Same as mentioned in suprapubic transvesical prostatectomy.
dvantages of Retropubic Approach
A
Better visualisation of prostatic fossa
Less chances of bladder injury.
ANESTHESIA
Spinal anesthesia
Epidural anesthesia.
POSITION
Supine with mild Trendelenburg position.
omplication
C
Same as mentioned in suprapubic transvesical prostatectomy.
TRANSURETHRAL RESECTION OF PROSTATE
It is considered as the gold standard surgical treatment of
benign hypertrophy of prostate.
ndications
I
BPH patients with small or medium size prostate
Patients with obstructive urinary symptoms with post
void residual volume more than 100 ml
Chronic retention of urine
Obstructive uropathy
Malignant prostate causing obstruction.
ontraindications
C
Huge prostate with estimated weight > 100 gm
Cardiac conditions (Risk of uid overload in TURP)
Hip joint pathology (Lithotomy position cannot be made)
Bladder diverticulum present
Large bladder stone (which cannot be managed
endoscopically)
If any other open urological surgery needs to be done
simultaneously.
ethods
M
Antiseptic dressing and draping of the operative eld is
done
The steps till bladder exposure are same as mentioned in
suprapubic transvesical prostatectomy
A self-retaining Millin’s retractor is applied, the bladder is
depressed by its third blade
Two gauze swabs are inserted into the retropubic space
just lateral to the prostate to visualize the anterior surface
of prostate clearly
Prostatic capsule is opened transversely about 1 cm
distal to bladder neck between 2 stay sutures
The cut capsular edges are held and the lateral lobes of
prostate gland are separated from their capsule by blunt
nger dissection
The upper prostatic urethra is divided with the help
of scissors and the lower prostatic urethra is divided
under vision for complete removal of prostate gland
Hemostasis is achieved by packing the prostatic fossa with
a roller bandage and compressing it for about 10 minutes
A Triway Foley catheter is inserted whose inated bulb is
placed in the prostatic fossa to provide tamponade eect.
The anterior prostatic capsule is closed with the help of
vicryl suture and a drain is placed in the retro-peritoneal
space of Retzius
Incision is closed in layers and continuous irrigation with
normal saline is started till the time urine becomes clear.
ANESTHESIA
Spinal anesthesia.
Figure 4: Transurethral resection of prostate
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