Surgery Osce

Colostomy Bag

• Two piece system colostomy bag (L)

• One piece system colostomy bag (R)
What are the indications of forming
a stoma?
• Feeding (Percutaneous endoscopic
gastrostomy)
• Lavage ( Appendisectomy)
• Decompression
• Diversion – To protect (defunction) distal
bowel anastomosis
• Permanent drainage – after excision in
rectal CA
 Types of colostomy
• Temporary colostomy - also known as
loop colostomy
• Normal site – Transverse colon @
Sigmoid colon
• End (Permanent) Colostomy
• Normal site – distal end of the divided
colon usually at the lateral edge of rewctus
sheath, 6 cm above & medial to iliac crest.
(Right iliac fossa)
 What is suitable site of forming a
stoma?
• Patient able to see the stoma while he is
standing up
• Away from scar and skin creases
• Away from body prominence and waistline
for clothes
• Easily assesible to the patient
• 5 cm from umbilicus
• Not under a large fold of fat
 Complications of stoma
• General
• 1) Stoma diarrhoea-fluid & electrolyte
imbalance
• 2) Nutritional disorder
• 3) Gallstone & Renal stone after ileostomy
(Reduced bile salt absorption?)
• 4)Psychosocial
 Specific Complications
• 1) Ischaemic/gangrene
• 2) Hemorrhage
• 3) Prolapse
• 4) Skin excoriation *
• 5) Parastomal hernia
• 6) Stenosis leading to
constipation/obstruction
 How to prepare patient?
• Psychosocial & physical preparation
• Explaination of indication & complication
• Marking the stoma site
• Advices by clinical nurse specialist in
stoma care
• Bowel preparation for colostomy operation
 How to rehabilitate patient?
• Inform the patient on function of colostomy bag
• Reassure the pt that he can live a normal life
with it
• Eat soft non bulky diet
• Change the bag when it is ¾ full
• Daily stoma inspection
• If complication arise seek, profesional help
• Psychosocial and sexual support
 How to prevent skin
excoriation?
• Remove appliance gently to prevent
stripping
• Use skin barrier (water) to prevent the skin
from contact with faeces
• Change the bag before it is full
 Ileostomy vs Colostomy
Ileostomy Colostomy

Site RIF LIF

Surface Spout Flush with skin

Contents Watery & Faeculent

erosive
Permanent Post AP resection of
stoma pancreatocolect rectum
omy
Temporary Low Hartmann’s
stoma anastomosis procedure
Nasogastric tube
 How to recognize?
• Multiple opening at the gastric end
• One proximal opening
• 3 markings (50,60,70 cm)
 Indications
• Diagnostic
• 1) to aspirate blood in GI bleeding
• 2) take sputum AFB in children
• 3) aspirate duodenal content (Giardia
lambdlia)
• Therapeutic
• 1) Decompression of stomach
• 2) Feeding
• 3) Rest the bowel
 Contraindications
• Base of skull #
• Oesophageal stricture
• Comatose patient because of absence of
gag reflex may cause aspiration ?
 Procedures
Seat the pt and inspect for nasal deformitie
• Warn pt about retching
• Lubricate the tube
• Pass horizontally backward through the
nose into the nasopharynx
• Ask patient to swallow
• Confirm the position
• Fix tube to adhesive tape
 4 anatomical position of narrowing
• Nose
• Nasopharynx
• Pharynx
• Esophagus
• Stomach (LES)
 How to confirm successful
insertion?
• Pumop air into syringe and auscultate for
gastric splash
• Put tube into water..No air coming out
• Aspirate content and test with litmus paper
• X ray
 Complications
• Wrong position into trachea causing
pneumonitis if feeding
• Traumatize nasal cavity causing epistaxis
• Goes into brain if # of basal skull or
cribriform plate
Sengstaken Blackmore Tube
 What are the purposes of the 4
channels?

• Inflation of the gastric balloon

• Inflation of the esophageal balloon
• Aspiration of gastric content
• Aspiration of esophageal content
 Indications
• Upper GI hemorrhage from
gastroesophageal varices
 Procedures
• Remove dental plates & insert a mouth guard
• Anaesthesize oropharynx by using 3-4 puffs of 50%
lignocaine spray
• Lubricate tube & pass through the mouth guard
• Confirm has pass through the stomach by injecting air into
the gastric lumen
• Fill the gastric balloon by slowly injecting 200-300 ml of air
• Gently withdraw the tube by pulling it against the LES
• Check with X ray to confirm position
• Inflate the esophageal balloon to 30-40 mmHg using a
spygnomanometer,3 way tap & a 50 ml syringe
• Seal & leave the tap in site
• Apply 250g of traction to the tube by means of a pulley
attached to the head of the bed
 Complications
• Esophageal perforation (pressure
necrosis)
• Aspiration pneumonia
• Airway obstruction
 Precautions
• Before passing the tube, check both
ballooons to ensure the absence of leak
• Regular esophageal suction, to prevent
aspiration pneumonia
• Check pressure within the esophageal
balloon every hour because some will leak
slowly
• Deflate the esophageal balloon 6 hours for
10 minutes to prevent pressure necrosis
Urinary catheter
 Foley’s Catheter
• Indication :-
• Continuous bladder drainage
• Monitoring urine output
• To assist the nursing care of incontinent
patient
• Relieve obstruction
 Procedures (Male)
• Hold the penis with sterile gauze,retract the
foreskin and cleanse with aseptic technique
• Insert 10 ml of 1% lignocaine into the urethra
using a sterile noozle and apply lignocaine jelly
at the tip of the catheter
• Insert a 14 G or 16G FC into the gel filled
urethra using forceps
• Ask pt to inspire during the process
• Confirm entry into the bladder & collect the urine
• Inflate the balloon by instiling sterile water
• Connect to urine bag
 Procedures (Female)
• Position the patient supine with the heels
together and the knees well apart
• Under adequate lighthing, cleanse the vulva with
aseptic technique
• Hold the swab with dressing forceps. Use only
once and swab from anterior to posterior
• Insert 5 ml of 1% lignocaine gel into the urethra
using a sterile noozle
• Proceed as for male
 Ways to avoid infection
• Use aseptic technique
• Cleanse vulva from Anterior to posterior
• Avoid leaving the catheter in situ for too
long
(2 weeks)?
 Non dwelling catheter vs Foley
catheter
• 1 opening at one end and another opening
at the other end
• For temporary use
 Contraindications
• Ruptured urethra
• Infection of urethra
• Urethral stricture
T tube
 Indications
• For post CBD exploration to drain the bile
while waiting for healing
• To prevent biliary leakage if there is
residual stone
• For post operative T tube cholangiography
• Maintain patency of biliary tract
• Stone removal with forceps and Dormia
basket
 Complications
• Biliary peritonitis
• CBD stricture
• Fistula formation
• Rupture of CBD during removakl
 What are the precautions in
removal of the tube
• Ensure that the tract is well formed and no
distal obstruction of CBD by doing a T
tube cholangiogram at 10 days post op
• Trial of clamping for a short period. Look
for pain, fever and jaundice if obstruction
still persist
 What are the contraindications for
removal
• Fever, jaundice
• Recurrence of pain after clamping the tube
• Leakage of bile around the tube after
clamping
• Achlouric stool
Suprapubic catheter
Suprapubic catheter
 Indications
• Urethral stricture or previous trauma
(BPH)
• Post operative urinary diversion eg
bladder neck surgery
• In acute retention to avoid urethral
damage
• Infection along the urinary tract eg
prostatitis,epididymitis
 Contraindications
• Contacted or decompressed bladder
• Gross hematuria with clot (lumen
inadequate to evacuate clot)
• Previous intraabdominal surgery involving
pelvis, small bowel may be encountered
beneath the inferior portion of the incision
 Procedures
• Pt is supine
• Palpate/percuss bladder
• Inject LA using spinal needle after wheal has
been raised. Select a site 1 @ 2 finger breaths
above the symphisispubis in the midline.
Infiltrate widely
• Localize bladder directing the spinal needle
roughly 30 degree from the vertical in the
midline aiming for tip of coccyx. Aspirate
frequently to ascertain entry into the bladder
• Incise skin, making a 2-3 mm stab incision
 Continued…
• Insert needle unit into bladder. Attach the syringe
onto the needle and carefully guide it toward the
bladder as with spinal needle previously. There
will be slight resistance as rectus fascia is
penetrated and urine will be aspirated into the
syringe as the bladder is entered. Advance the
needle for another 2 cm to be sure this is well
within the bladder
• Insert the catheter through the needle after
removing the syringe
• Ascertain position in the bladder by aspirating
• Secure catheter with silk suture
• Attach catheter to urinary bag
• Apply sterile dressing.Use Povidone
Sutures
 Ideal sutures
• All purpose
• Sterile
• Non capillary, non allerginic, non
carcinogenic, non ferromagnetic
• Easy to handle
• Minimal tissue reaction
• Capable of holding securely when knotted
 Monofilament
• Made of single stranded material
• Adv- Less resistance as they pass through
tissue
• Resist harboring organism which may
cause suture line infection
• Tie down easily
• Used in vascular surgery
• Contoh : Prolene, Dafilone, Ethilon
 Multifilament (Braided sutures)
• Several filament twisted or braided together
• Adv :-
• Greater tensile strength, pliability & flexibility
• Coated multifilament pass smoothly through
tissue and enhance handling characteristics
• Do not tend to slip in knot
• Used in intestinal procedures
• Contoh :- Vicryl & Silkam
 NaTURAL Absorbable
sUTURES
• Suture prepaid from collagen of healthy
mammals or from synthetic polymers
• Natural absorbable sutures – (catgut) –
sheep intestine @ serosa of beef intestine
• For soft tissue approximation
• Digested by body enzymes
• Cause moderate tissue reaction
• Contoh :- Catgut
 Synthetic Absorbable Sutures
• For soft tissue approximation
• Hydrolysed and less tissue reaction
compared to natural absorbable suture
• Eg Vicyl (Polyglactin 910)
• Monocryl (Polyecaprone 25)
 Non absorbable sutures
• Not digested by body enzymes or hydrolized in body tissue
• Application :-
• Tissue approximation includes CVS,ophthalmic,CNS
• Exterior skin closure
• Patient with history of reaction to absorbable sutures like
tissue hypertrophy or keloidal tendency
• Contoh :-
• Silk
• Nylon – Ethilon
• Polyesther fibre – Mersilene
• Polyprophylene - Prolene
 Colour/Material/Usage
• Blue – Prolene ( for skin closure)
• Black – Silk (Tendon/muscle)
• Straw coloured – Catgut (Episiotomy
closure)
• Purple - Vicryl (Rectus sheath closure)
Others