OPERATIONS

Dr.Krishnanand
Professor & HOD
Department of Surgery
Headings
• Definition
• Indications
• Contraindications
• Anaesthesia
• Position
• Procedure/Steps
• Complications
Surgical procedures
• Inguinal Hernia
• Hydrocoele
• Intercostal Tube Drainage
• Appendicectomy
• Suprapubic Cystostomy/Catheterisation
• Incision & Drainage
• Vasectomy
 HERNIA

• A hernia is defined as abnormal protrusion of whole or a part of a

viscus through the wall that contains it
Indications
• Indirect Inguinal Hernia
• Direct Inguinal Hernia
Anesthesia: Spinal anesthesia.

Positon of the patient: Supine.

Procedure :
• Painting and draping is done.
• Incision- Inguinal incision.

• Starting medially at the pubic tubercle and laterally extending beyond the deep inguinal ring 2
cm above and parallel to the inguinal ligament.
• Two layers of subcutaneous tissue
➢ Superficial fatty layer—fascia of camper and
➢ deeper membranous layer—fascia of Scarpa
are incised in the same line as skin by using diathermy/blade.
• External oblique aponeurosis is exposed deep to the subcutaneous tissue.

• A nick is made in the external oblique aponeurosis and it is incised medially

dividing the superficial inguinal ring and laterally beyond the deep inguinal ring.

• The upper flap of external oblique aponeurosis is dissected upwards and the
conjoint tendon is exposed.
• The lower flap of external oblique aponeurosis is dissected downwards
to expose the shining inguinal ligament from pubic tubercle medially to
laterally beyond the deep inguinal ring.

• The cremasteric muscle and fascia is incised and deep to this internal
spermatic fascia is incised.

• The cord structures are splayed in between fingers and the hernial sac
is identified by shiny white margin.
• The margin of the hernial sac is picked up by a pair of hemostatic forceps
and the hernial sac is dissected by sharp dissection from the cord
structures taking care not to damage the vas deferens and the testicular
vessels.

• The hernial sac is dissected from the fundus to the neck of the sac.

• The hernial sac is opened at the fundus and the interior of the sac is
inspected and the contents are reduced.
• A standard sized prolene mesh is required for inguinal hernia.

• The mesh is fixed to the inguinal ligament starting medially at the fascia
over the pubic tubercle extending laterally along the inguinal ligament
beyond the deep inguinal ring .

• The mesh is fixed above to the conjoint tendon .

• The split lateral end of the mesh is re-sutured beyond the spermatic cord.

• The external oblique aponeurosis is sutured using running suture creating

a new superficial inguinal ring.

• The skin and subcutaneous tissue is apposed using interrupted sutures.

Complications
• Haemorrhage
• Infection
• Recurrence
• Seroma formation
• Bowel injury
• Orchitis
• Urinary retention
• Neuralgia
Appendectomy
Anesthesia –General or spinal

Position of the patient—supine.

Procedure:

• Antiseptic painting and draping.

• Incision: McBurneys’ gridiron incision.

• An oblique skin incision of about 3 inches (one inch above and two inches below the
spinoumbilical line) is made at right angle to the right spinoumbilical line passing
through the McBurneys’ point .

• The skin and subcutaneous tissues are incised in the same line.
• A nick is made in the external oblique aponeurosis and it is incised along
the direction of its fibers

• The internal oblique muscle is exposed and deep to it lies the transversus
abdominis muscle.

• A Mayo’s scissor is thrushed with the blades closed through the internal
oblique and the transversus abdominis muscle and the blades are opened
up to split both these muscles along the direction of their fibers
• Two Langenbachs’ retractors are inserted deep to these muscles and the
peritoneum is exposed.

• The peritoneum is lifted by two pairs of hemostatic forceps and a nick is

made in the peritoneum and the peritoneal incision is then extended
along the line of skin incision

• As soon as peritoneum is opened turbid or clear fluid may escape from

the peritoneal cavity (This fluid may be due to peritoneal reaction to
local inflammation).
• The cecum is identified by its pale color, presence of taenia coli and
absence of mesentery.

• The appendix is held by Babcock’s tissue forceps.

• The mesoappendix is clamped with one or more pair of hemostatic

forceps and divided and ligated.
• The base of the appendix is crushed by applying a hemostatic forceps. A
ligature is then passed around the base of the appendix at the crushed area
and the base of the appendix is ligated.

• A hemostatic forceps is applied at the appendix about 5 mm distal to the site

of ligature at the base of appendix.

• The appendix is divided with a knife close to the forceps and the stump of
the appendix is swabbed with povidone iodine lotion

• The mesoappendix stump is checked for bleeding

• The wound is closed in layer.

Complications
• Haemorrhage
• Infection
• Seroma formation
• Bowel injury
• Faecal fisula
• Neuralgia
• Stump appendicitis
 HYDROCELE
• A hydrocoele is an abnormal collection of serous fluid in a part of the
processus vaginalis, usually the tunica vaginalis.
Hydrocoele can be produced in four different ways

1. By connection with the peritoneal cavity via a patent processus vaginalis

(congenital).

2. By excessive production of fluid within the sac, e.g. a secondary

hydrocoele.
3. By defective absorption of fluid; this appears to be the explanation for

most primary hydrocoeles, although the reason why the fluid is not

absorbed is obscure. They are called vaginal hydrocoeles.

4. By interference with the lymphatic drainage of scrotal structures.

 Treatment
In infant or children

• Congenital hydrocoeles are treated by herniotomy if they do not resolve

spontaneously.

In Adults

• There are three main surgical techniques for hydrocoeles :

1. Plication :

➢ Lord’s operation is suitable when the sac is reasonably thin-walled.

➢ There is minimal dissection and the risk of haematoma is reduced.

2. Eversion:

➢The sac is opened and everted behind the testis, with placement of the testis in

a pouch prepared by dissection in the fascial planes of the scrotum (Jaboulay’s

procedure)

➢Large big sacs.

3. Excision : Not recommended

• Anaesthesia : Infants & Children – GA
Adult – SA/LA
• Position : Supine
Procedure
1.Anterior scrotal skin is held taut over the hydrocele with one hand and an
incision made through skin and dartos muscle parallel to median raphae.
2. An artery forceps applied to the remaining coverings and the tunica vaginalis

before incising into the hydrocele will enable the suction tube to be inserted more

easily to drain the fluid.

3. The opening is then enlarged to a size through which the testis can be delivered.

4. The aim of the operation is to leave the testis so that the fluid produced by its

tunica albuginea can drain into a different tissue plane.

• Transilluminant Sac containing straw-colored fluid
5. This is mostly simply achieved by several absorbable sutures which plicate the tunica

vaginalis so that it lies as a cuff behind the testis.

6. The dartos and scrotal skin are then drawn back over the testis and closed.

7. The scrotal incision is satisfactorily closed with a continuous absorbable haemostatic

suture in the dartos, and a subcuticular absorbable suture in the skin.

 Other modalities
➢ Aspiration of hydrocele is only a very temporary solution as the fluid re-collects.
➢ Sclerosant injection after aspiration can obliterate the space and prevent recurrence.
▪ However, this may cause severe pain unless mixed with a short and long acting local
anaesthetic agent.
▪ A mixture containing 2 ml of a 3 percent solution of sodium tetradecyl sulphate mixed
with 5 ml of 1 percent lignocaine and 5 ml of 0.25 percent bupivicaine has proved
satisfactory.
Complications

• Hematoma – due to trauma

• Pyocele – due to infection
• Calcification of sac wall
• Rupture of hydrocele sac – traumatic/ spontaneous
• Hernia of hydrocele sac
• Atrophy of testis
Circumcision
 Indications
In infants and young boys,

• At the request of the parents for social or religious reasons.

• True Phimosis

• BXO (Balanitis xerotica obliterans)

• Recurrent attacks of balanoposthitis

• Recurrent urinary tract infections with an abnormal upper urinary tract.

In adults

• Inability to retract the foreskin for intercourse,

• For splitting of an abnormally tight frenulum

• Recurrent balanitis.
 Contraindications

• Acute infection of glans or prepuce

• Hypospadias

• Chordee

• Blood dyscrasias
• Anaesthesia : Children – GA
Adult – SA/LA
• Position : Supine
Procedure

• The penis is cleaned with an antiseptic solution (povidone iodine) and

draped with a sterile sheet.

• Infiltration anesthesia using 1% lignocaine injection (without adrenaline).

• The local anesthetic is injected all around the base of the penis.

• Wait for 3-5 minutes.

• Tip of the prepuce is grasped with two pairs of mosquito artery forceps

• Adhesion between the prepuce and glans penis is separated.

• A dorsal cut is made in the prepuce with scissors extending proximally up to 5

mm of the corona glandis.

• The cut is then taken around the penis to the ventral aspect toward the frenulum
and the preputial skin is excised
• The skin edges are then sutured with 3-0 chromic catgut sutures.

• The dorsal and ventral midline sutures are applied first and the remaining cut
edges of the prepuce is sutured with interrupted 3-0 chromic catgut sutures.

• A figure of 8 stitch in ventral mid line controls the frenular artery bleed.

• A light dressing is applied.

Complications
• Bleeding

• Infection

• Excessive skin removal with scarring

• Inadequate skin removal

• Injury to the glans,urethral injury and injury to penile shaft

• Retention of urine
INCISION AND DRAINAGE
 Abscess
• Abscess is localized collection of pus.

• Treatment of an abscess is incision and drainage (I&D).

• Smaller abscesses (<5 mm) may resolve spontaneously with the application of
warm compresses and antibiotic therapy.

• Larger abscesses will require I&D due to increase in collection of pus,

inflammation, and formation of the abscess cavity, which lessens the success of
conservative measures.
Indications:
• Palpable, fluctuant abscess

• An abscess that does not resolve despite conservative measures

• Large abscess (>5 mm)

Contraindications
• Extensively large or deep abscesses or perirectal abscesses that may
require surgical debridement and general anesthesia

• Facial abscesses in the nasolabial folds (risk of septic phlebitis

secondary to abscess drainage into the sphenoid sinus)
 Step 1

• Prepare the surface of the abscess and surrounding skin with

povidone-iodine or chlorhexidine solution and drape the abscess
with sterile towels.

• Perform a field block by infiltrating local anesthetic around and

under the tissue surrounding abscess.
Step 2
• Make a linear incision with a no. 11 or 15 blade into the abscess.
 Step 3
• Allow purulent material from the abscess
to drain.

• Gently probe the abscess with the curved

hemostatic forceps to break up
loculations.

• Attempt to manually express

purulent material from the abscess.

 Step 4
• Insert gauge packing into the abscess with
hemostats or forceps.

• Dress the wound with sterile gauze and tape.

 Hilton’s Method of Incision and Drainage

• When the abscess is situated in an important site containing major vessels and nerves then

there is possibility of injury of underlying structures during drainage of abscess.

• To avoid this, the abscess drainage in important site is done by Hilton’s method.

• The skin and subcutaneous tissues are incised with a knife.

• The point of a hemostat or a sinus forceps is pushed through the most prominent part of the

swelling and the blades are then opened.

• The opening is thus enlarged and pus drained.

• A finger may be introduced into the abscess cavity and all the loculi broken.

• Placement of drain: A rubber drain is inserted into the depth of the abscess
cavity; and external part is secured to the wound margin with the help of suture.

• Drain left for at least 24 hours.

 Complications
• Inadequate anesthesia
• Pain during and after the procedure
• Bleeding
• Reoccurrence of abscess formation
• Septic thrombophlebitis
• Necrotizing fasciitis
• Fistula formation
• Damage to nerves and vessels
• Scarring
 Venous Cut down(Venesection)

• This involves exposure of a vein, venotomy and introduction of a wide bore

cannula inside the vein under direct vision.

• A long cannula may be passed down the vein up to the superior vena cava
and central venous pressure (cVP) may be measured
 Indications of venesection

• Intravenous access in shocked patient requiring rapid infusion of fluid

• Prolonged period of intravenous fluid therapy

• Parenteral nutrition

• Measurement of central venous pressure.

 Sites
• Great saphenous vein at the ankle or at the groin

• Basilic vein at the arm

• Cephalic vein at the deltopectoral groove.

 Procedure
• Wash hands and wear sterile gloves

• The area is cleaned with an antiseptic solution (povidone iodine) and draped with
towel

• Inject 1 % lignocaine at the site transversely across the vein to be cannulated

• A small transverse incision is made across the selected vein.

• The incision is deepened up to the subcutaneous tissue

• The subcutaneous tissue is incised

• The vein is isolated by blunt dissection

• Two ligatures are passed around the vein. The distal one is tied and held by a
hemostatic forceps

• A curved needle is passed through the middle of the basilic vein wall and the
vein wall in front of the needle is incised
• A no. 6 or 9 sterile infant feeding tube is introduced through the venotomy and
the cannula is advanced proximally so that its tip lies in the superior vena cava.

• The proximal ligature is tied to fix the cannula within the vein

• The end of the cannula is connected to an intravenous fluid channel

• The skin incision is closed with interrupted skin sutures

• The cannula is fixed to the skin by a suture passed around the cannula

• Sterile dressing is applied.

 Complications

• Infection

• Bleeding

• Superficial thrombophlebitis

• DVT

• Through and through puncture leading to perforation of posterior wall

 Intercostal drainage tube

• An intercostal drain is a flexible plastic tube that is inserted through the chest
wall into the pleural space.

• Drainage of the pleural space by means of an ICD tube is the commonest

intervention in thoracic trauma.
 Indications
• Pneumothorax
• Pleural effusion
- Chylothorax
- Empyema
- Hemothorax
- Hydrothorax

• Postoperative – Thoracotomy
• As a drain after removal of lung.
Contraindication

• Uncorrected coagulopathy

• Diaphragmatic hernia

• Severe pleural adhesion

PATIENT PREPARATION
• Consent – Informed and Written

• Preparation of materials

• Positioning and marking the site

• Oxygen saturation monitoring

 PREPARATION OF MATERIALS
• Sterile gloves and gown • Curved and straight artery forceps

• Antiseptic solution • Chest tube with connecting tube

• Sterile draping sheets • Drainage system ready with 100 cc

saline filled up to mark
• Local anaesthetic solution
• Suture silk no 1
• Sterile gauze
• Dressing material
• Scalpel with blade no. 11
Step 1 – Position of patient

• Elevate the head of the bed 30 to 60

degrees

• Place (and restrain) the arm on the

affected side over the patient’s head.
 Step 2 – Preparation of skin and LA
• Prepare the skin with povidone-iodine
solution.

• Drape the site with fenestrated sheet.

• Using the 10 ml syringe and 25 gauge

needle, infiltrate 1% solution of Lidocaine
at the incision area.
Step 3 – Incision

• Make a 2 to 3 cm transverse incision through the skin and the

subcutaneous tissues overlying the interspace.

• Extend the incision by blunt dissection through the fascia toward

the superior aspect of the rib above.

• After the superior border of the rib is reached, close and turn the
artery forceps, and push it through the parietal pleura with
steady, firm, and even pressure.
• Open the artery forceps widely, close it, and
then withdraw it.

• Be careful to prevent the tip of the clamp from

penetrating the lung.

• Insert an index finger to verify that the pleural

space, not the potential space between the
pleura and chest wall, has been entered. Check
for unanticipated findings, such as pleural
adhesions, masses, or the diaphragm.
Step 4 – ICD insertion
• Grasp the chest tube so that the tip of the
tube protrudes beyond the jaws of the clamp,
and advance it through the hole into the
pleural space using your finger as a guide.
• Direct the tip of the tube posteriorly for fluid
drainage or anteriorly and superiorly for
pneumothorax evacuation.
• Advance it until the last side hole is 2.5 to 5
cm
(1 to 2 inches) inside the chest wall.
• Attach the tube to the previously assembled
suction-drainage system
A. B
.

C. D
.
 Step 5 – Confirm position
• Confirm the correct location of the chest tube by the visualization of column
movement within the tube with respiration or by drained pleural fluid seen
within the tube.

• Ask the patient to cough, and observe whether bubbles form at the waterseal
level.

• If the tube has not been properly inserted in the pleural space, no fluid will drain,
and the level in the water column will not vary with respiration
• Fix the tube to skin using silk
no 1 suture.

• Proper dressing.

• Post procedure X-ray and note

position and kinking.
PRE-OP ICD POST-OP ICD
 COMPLICATIONS
➢Improper placement

• Horizontal (over the diaphragm) –

Acceptable for hemothorax; should be repositioned for pneumothorax

• Subcutaneous - Must be repositioned

• Placed too far into the chest (against the apical pleura) - Should be retracted

• Placed into the abdominal space - Should be remove

➢Bleeding

• Local - Usually responds to direct pressure

• Hemothorax (lung vs intercostal artery injury) - Might require thoracotomy if it does not
resolve spontaneously

➢Organ penetration (usually requires surgical repair)

• Stomach, colon, or diaphragm

• Lung - Occurs as a result of pleural adhesions or use of a thoracostomy tube trocar

• Liver or spleen
➢Tube dislodgement

➢Empyema - Chest tube (foreign object) could introduce bacteria into the pleural
space

➢Retained pneumothorax or hemothorax - Might require insertion of a second

chest tube
SUPRAPUBIC CYSTOTOMY
• A form of urinary diversion, in which a self retaining catheter is placed
into the bladder via the suprapubic region for purpose of draining
urine.
INDICATION
• Urine retention when urethral catherization fails.

• Ruptured urethra

• Urethero-cutenous fistulae

• Periurethral abscess

• Extravasation of urine

• Chronic retention in neurogenic bladder

TYPES

• Open or Percutaneous

• Temporal or Permanent

• Emergency or Elective
PRE-OP PREPARATION
• History and examination

• Investigations;
- Clotting profile, Abd USG

• Informed Consent

• Preparation of materials

• Pre – Op shaving

• Pre – Op Antibiotics
ANAESTHESIA

• Local

• Spinal

• GA

POSITION -Supine
PROCEDURE
• The skin is prep with povidone-iodine solution (from the nipple line to the
mid – thigh) and draped exposing the supra – pubic region.

• The transverse incision along the skin crease 2 finger breath above the
pubic symphysis (heals better less likely to herniate)

• Sub umbilical median incision, 3 – 5 cm long, 3 cm from the symphysis

• The incision traverse the subcutaneous tissue and fascia.

• The rectus sheath opened

• The muscles are separated at the midline with artery forceps and retracted

laterally

• The transversalis fascia, preperitoneal fat and peritoneum are carefully

pushed upwards until the bladder is exposed

• The bladder is pale wall with vessels courses over the surface
and urine can be aspirated with needle and syringe

• The wall of the bladder is fixed with two stay sutures (Silk 1-0)

• Using electrocautery or knife, a transverse incision is made

about 2cm distal to the fundus between the stay sutures

• The bladder is then emptied by suction

• The interior explored with the finger to exclude calculi,

diverticuli and tumor.
• The suprapubic catheter is placed through the
abdominal wall by stab incision in the upper skin flap,
inserted into the bladder

• The catheter is secured with purse string (Vicryl 2-0)

• The balloon is then inflated

• The catheter then anchored to the skin with nylon – 2-

0, before wound closure and continuous drainage
established.
Abdominal
midline
• The wound is closed in layers; rectus is approximated with vicryl 2-0 and
skin with nylon 2-0.

• Wound is cleaned and dressed.

COMPLICATIONS
• Haematuria

• Surrounding organ injury

• Catheter blockage

• Dislodgment

• Skin site infection

• UTI

• Stone formation