LIST OF OPERATIONS I HAVE DONE AND HOW I DID IT ABOVE THE KNEE AMPUTATION

Transcription

1 LIST OF OPERATIONS I HAVE DONE AND HOW I DID IT ABOVE THE KNEE AMPUTATION Patient supine under SAB/CLEA/General Anesthesia Incision made creating anterior and posterior skin flaps on the thigh Superficial vessels cut and ligated Flaps of skin and subcutaneous tissue reflected proximally Quadriceps muscles cut; bleeders ligated Femoral vessels and nerve identified at the subsartorial canal; Femoral vessels individually identified, divided and doubly ligated Posterior muscle group cut; bleeders ligated Sciatic nerve identified divided and ligated Periosteum of femur elevated Femur cut with bone saw Edges of stump bone filed Anterior and posterior myofascial flap sutured with figure of eight using vicryl 0 Subcutaneous tissue approximated by inverted T sutures using chromic 2.0 Skin closed interruptedly Dry sterile dressing placed.

2 APPENDECTOMY (Acute Perforative Appendicitis with Generalized Peritonitis) : Patient supine under SAB/CLEA/General Anesthesia Incision made ( Rocky-Davis with Fowler-Weir/ Right Paramedian / Midline ), carried from skin through subcutaneous tissue Fascia cut and opened, (Rocky-Davis, External oblique aponeurosis cut along its fibers; Right paramedian, Anterior Rectus Sheath cut and opened longitudinally; Midline, opened along linea alba) Muscle splitting along muscle fibers done for Rocky-Davis and Right paramedian incisions Peritoneum entered ( Rocky-Davis, peritoneum cut and opened transversely; Right paramedian, Posterior Rectus Sheath and peritoneum cut and opened longitudinally; Midline, peritoneum cut and opened longitudinally) Intra-operative Findings noted Intra-abdominal purulent discharge evacuated Appendix identified Mesoappendix serially clamped, divided and ligated Base of appendix tied, milked, clamped and cut Appendiceal stump painted with betadinized cotton Copious peritoneal lavage Correct sponge/instrument count Peritoneum closed continuously using vicryl 0 for Rocky-Davis; Peritoneum with posterior rectus sheath closed continuously for Right paramedian; Peritoneum and Fascia closed as single layer in midline incisions External Oblique aponeurosis closed continuously in Rocky-Davis; Anterior Rectus sheath closed continuously in Right paramedian NSS was Skin left open Wet to dry sterile dressing placed.

3 APPENDECTOMY (Acute Non-Perforative Appendicitis) : Patient supine under SAB/CLEA/General Anesthesia Incision made ( Rocky-Davis[transverse] and McBurney[oblique]) carried from skin through subcutaneous tissue External oblique aponeurosis cut and opened along its fibers Muscle splitting along fibers Peritoneum entered Intra-operative Findings noted Appendix identified Mesoappendix serially clamped, divided and ligated Base of appendix tied, milked, clamped and cut Appendiceal stump painted with betadinized cotton Correct sponge/instrument count Peritoneum closed continuously using vicryl 0 External Oblique aponeurosis closed continuously using vicryl 0 NSS was Skin closed interruptedly using silk 4.0 Dry sterile dressing placed.

4 BELOW THE KNEE AMPUTATION Patient supine under SAB/CLEA/General Anesthesia Incision made creating Long Posterior Flap carried from skin through subcutaneous tissue Superficial vessels ligated Anterior muscle group cut; bleeders ligated Anterior tibial vessels individually identified, divided and doubly ligated Deep peroneal nerve ligated proximally Lateral muscle group cut; bleeders ligated Posterior tibial vessels identified at the posteromedial aspect of tibia, individually identified and doubly ligated Posterior tibial nerve highly ligated Periosteum of tibia-fibula elevated Tibia-fibula individually cut with Giggli saw Fibular vessels identified individually, divided, and ligated Posterior muscle group cut; bleeders ligated Edges of tibia-fibular stump bone filed Posterior myofascial flap sutured with the anterior myofascial flap by figure of eight vicryl 0 sutures Subcutaneous tissue approximated with inverted T sutures using chromic 2.0 Skin closed interruptedly using nylon 4.0 Dry sterile dressing applied.

5 CHOLECYSTECTOMY Patient supine under SAB/CLEA/GA Incision made carried from skin through subcutaneous tissue Midline Fascia cut and opened through linea alba Kocher s (Right Subcostal) Anterior rectus sheath cut and opened Right belly of Rectus muscle cut Posterior Rectus sheath cut and opened Peritoneum cut and opened Exploration of entire abdomen carried out Intra-operative findings noted Retractors applied accordingly Gallbladder identified and clamped with a Kelly at the ampulla applying traction Triangle of Calot dissected, cutting the peritoneum that covers the area; Cystic duct identified, isolated and a temporary silk 4-0 ligature applied. Intra-operative cholangiogram done, findings noted Cystic artery identified, isolated, ligated and divided Gallbladder deperitonealization done and dissected from the liver bed using electrocautery Cystic duct divided and doubly ligated Common bile duct palpated Peritoneal lavage Complete sponge and instrument count Closure layer by layer Peritoneum and Fascia Vicryl 0 continuous Subcutaneous layer chromic 2-0 inverted T-sutures Skin silk 3-0 interrupted sutures Dry sterile dressing placed

6 FISTULOTOMY Transsphincteric fistula Intersphincteric fistula Simple Low Fistula Intersphincteric/Transsphincteric Patient supine on lithotomy position/ prone on jackknife position under SAB/CLEA Rectal speculum inserted Internal opening located with use of probe inserted on the external opening following the fistulous tract carefully Incision made with probe as guide starting on the external opening carried from skin through subcutaneous tissue, and division of overlying anoderm, and: IntersphinctericFistula - internal sphincter up to the internal orifice of the fistula Transsphincteric Fistula external and internal sphincters up to the internal orifice of the fistula Necrotic tissues removed by curettage OS packing

7 HEMORRHOIDECTOMY Patient supine positioned into lithotomy under SAB Lord s maneuver Hill-Ferguson retractor inserted Inspection done Wet sponge inserted as rectal pack Hemorrhoidal clamp applied and retracted hemorrhoids downwards Hemorrhoidal pedicle suture-ligated with chromic 2.0 Elliptical incision made on the anoderm and mucosa overlying the hemorrhoid towards pedicle Continuous running suture made to close mucosal defect anchoring to underlying internal sphincter Anoderm left open Saline irrigation Wet sponge removed Anal packing with small wet sponge Dry sterile dressing placed

8 HERNIORRHAPHY BASSINI : patient supine under asepsis and antisepsis technique sterile drapes placed incision done external oblique aponeurosis cut and opened spermatic cord identified cremasteric muscle opened hernial sac identified and separated from rest of spermatic cord hernial sac ligated highly inguinal floor repaired (Bassini internal oblique muscle, transversus abdominis muscle, and transverse aponeurosis and fascia approximated to the iliopubic tract and the shelving of the inguinal ligament with interrupted sutures.) secured Correct OS and instrument count verified Cremasteric muscle closed continuously using chromic 3.0 External oblique aponeurosis closed by continuous interlocking using vicryl 0 Subcutaneous tissue approximated by inverted T sutures using chromic 3.0 Skin closed subcuticularly using vicryl 4.0 Dry sterile dressing applied

9 HERNIOTOMY Patient supine under General Anesthesia Inguinal transverse incision made, carried from skin through subcutaneous tissue External Oblique Aponeurosis cut and opened along its fibers Ilioinguinal nerve identified and spared Spermatic cord identified Cremasteric muscle opened Hernial sac identified and isolated. Freed from rest of spermatic cord structures up to internal ring. High ligation of the hernial sac done. External oblique aponeurosis closed using vicryl 2.0 continuous interlocking sutures Subcutaneous tissue reapproximated using chromic 4.0 interrupted sutures Skin closed subcuticularly using vicryl 5.0 suture. Dry sterile dressing applied.

10 INCISION AND DRAINAGE Intersphincteric abscess Ischiorectal abscess Perianal abscess Patient supine on lithotomy position/prone on jackknife position under SAB Inspection done Findings noted Incision made over fluctuant mass Perianal Abscess - Ellipse incision, radially in relation to the anal opening Ischiorectal Abscess cruciate incision over inflamed area Intersphincteric Abscess with internal sphincterotomy Pus drained Cavity of the abscess explored breaking loculations Necrotic tissues removed NSS with hydrogen peroxide wash OS packing