THYROIDECTOMY

o Mobilization and dissection

o thyroid capsule dissected away from it on
both sides.
o sternohyoid & sternothyroid muscle
retracted laterally
o cleavage plane created between the thyroid
gland and the strap muscles,
o cervical fascia incised in the midline,
o Lower flap created by subplatysmal
dissection up to suprasternal notch in the
midline
o Upper flap created by subplatysmal
dissection up to the notch of the thyroid
cartilage
in the midline of the dissection
o transverse curved incision on skin crease or
2 cm above sternal notch, carried down to
the platysma
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine with neck hyperextended
WOUND CLOSURE:
o light dressing
o subcuticular suturing of skin with vicryl 4-0
o platysma muscles apposed, dermis
apposed,
o strap muscles apposed at midline, chromic
2-0
PARTIAL (subtotal) THYROIDECTOMY
o Correct count
o Drain (rational placement)
o Lavage or irrigation
o Hemostasis
o segment approximated to the trachea
o suture ligation of the thyroid parenchyma
and surface veins.
o gland transected
o multiple hemostats applied at the thyroid
parenchyma
TOTAL LOBECTOMY
o Hemostasis
o pyramidal lobe removed when present
o lobe and isthmus dissected from the
tachea, and remove

o inferior thyroid artery ligated

o parathyroids identified and spared
o recurrent laryngeal nerve identified and
spared
o superior thyroid artery and vein ligated
close to the gland to avoid ligation of superior
laryngeal nerve.
o middle thyroid vein ligated
o Lobe retracted medially and anteriorly
using one hand while dissecting posteriorly
(close to the gland)
PAROTIDECTOMY
o LOWER FLAP: dissection of the skin
downward and posteriorly toward the mastoid
process
o UPPER FLAP: traction provided upward and
medially on the dissected skin, and laterally
toward the external auditory canal.
o FLAP formation:
o skin and fat elevated using scalpel, sharp
and blunt dissection upward, medially,
laterally, downward, and posteriorly.
o deep incision made into the superficial
cervical fascia
o (anteriorly: fat and platysma ; posteriorly:
fat only)
o Modified Y incision making a vertical preand
o postauricular incisions united
approximately at the angle of the mandible,
forming a Y
which converge with a transverse incision 3
cm below the mandible
o STERILE DRAPES PLACED
o the lateral angle of the eye and labial
commisure uncovered
o ASEPSIS/ANTISEPSIS done
o Patient supine, head turned to the
contralateral side with neck hyperextended
o may sacrifice the great auricular nerve
and the posterior facial vein, which are both
very
closely situated in the vicinity of the lower
flap and the lower parotid border
FACIAL NERVE IDENTIFICATION:

o main trunk of the facial nerve exposed at a

depth of about 1.5 cm. from the external
surface of the mastoid process by dissecting
directly downward along the anterior
border of the mastoid process above the
attachment of the posterior belly of the
digastric muscle.
o hemostat inserted between the mastoid
and the gland
o parotid fascia incised carefully & the
superficial lobe of the parotid mobilized
o distal phalanx of the left index finger placed
on themastoid, pointing to the eye of the
patient
RESECTION OF THE SUPERFICIAL LOBE
RESECTION OF THE DEEP LOBE
o duct then ligated and divided
o the superficial lobe totally mobilized and
resected Stensens duct encountered as the
dissection carried toward the ends of the
branches of the facial nerve
o further anterior nerve dissection toward
the periphery of the gland,
o with gentle traction of the gland
o deep lobe removed carefully, working
under the
o Hemostasis
o facial nerve by the piecemeal dissection
technique.
o Complete removal of the parotid gland
reveals the ff structures: (acronym VANS)
o vein: internal jugular
o arteries: external and internal carotid
o nerves: IX, X, XI, XII
o anatomic entities starting with S:styloid
process; muscles: styloglossus,
stylopharyngeus, stylohyoid
o LIGHT DRESSING
o subcuticular suturing of skin with
absorbable suture
o dermis apposed,
o WOUND CLOSURE: platysma muscles
apposed,
o CORRECT COUNT
o DRAIN (rational placement)

o LAVAGE or IRRIGATION
o the contralateral side
o Light dressing
o Continuous 4-0 vicryl for the approximation
of the platysma muscle and subcuticular
suture for the skin
o A two-layer closure
o Placement of suction drains
o Thorough irrigation with saline
o Completion of the dissection
o Transection & ligation of facial vein
o Tail of parotid transected along with the
attachments of sternocleidomastoid muscle
o External maxillary artery ligated and
transected
o A fine silk suture ligature then placed
distally. Distal to the suture ligature free tie
secured, and the vessel cut between the two
distal ligatures
o Internal jugular vein clamped at this point
and tied with 2-0 silk passed about the vessel
o The muscle and lymph node mass reflected
upward to the point at which the internal
jugular vein immobile
o Posterior belly of the digastric and
stylohyoid muscles removed with the contents
of the
dissection
o hyoglossus muscle from deep plane of
dissection, while the digastric and stylohyoid
muscles form the inferior plane
o Ligation & division of Wharton duct and
tributaries of the lingual vein
o Preservation of hypoglossal nerve and the
accompanying veins
o Division of lingual nerve and the
submandibular gland duct
o Dissection of submandibular prevascular
and retrovascular lymph nodes into the
specimen area
o Exposure & transection of the facial vessels
o Exposure & preservation of ramus
mandibularis
o Dissection of the Submandibular Triangle
o Dissection of internal jugular vein

o Preservation of the branches of the cervical

plexus
o Spinal accessory nerve and the transverse
cervical vessels divided
o Removal of all the contents of the posterior
triangle
o Fibrofatty tissue of the posterior triangle of
the neck dissected forward and downward
in a plane immediately lateral to the fascia of
the splenius and the levator scapulae
muscles
o Identification and preservation of strap
muscles
o The nodes, fat, and fascia reflected
downward over the anterior belly of the
digastric m
muscle
o Dissection of submental triangle, crossing
the midline to the opposite anterior belly of
the digastric muscle
o External maxillary artery and anterior facial
vein transected at the mandibular edge.
Including in the dissection the pre- and
retrovascular lymph nodes
o Spinal accessory nerve transected and with
associated lymph nodes reflected upward
o Preservation of phrenic nerve
o Superior belly of the omohyoid muscle
detached from the hyoid bone
o Inferior belly of omohyoid transected
o Dissection carried upward following the
plane formed by the anterior edge of the
superior belly of the omohyoid muscle
o Suture-ligation with 1-0 silk then division of
internal jugular vein in between ligatures
o Dissection of internal jugular vein off the
internal carotid artery and vagus nerve
o Ansa hypoglossi is transected
o Carotid sheath opened
o Sternocleidomastoid muscle reflected
upward, using blunt and sharp dissection
o Ligation of external juguIar with distal
suture ligature and a proximal tie, then
transected
o Transection of sternocleidomastoid muscle

o Subclavian vein, the thoracic duct on the

left side and the accessory duct on the right
side preserved
o posterior edge of the sternocleidomastoid
muscle opened
o Space anterior to the sternocleidomastoid
muscle opened, exposing the carotid sheath
o Incision made starting below at the anterior
edge of the sternocleidomastoid muscle,
then along the anterior edge of the superior
belly of the omohyoid muscle to the hyoid
bone
o Superior flap created
o Skin incision created from the inferior
border of mastoid going down along
sternocleidomastoid muscle and curved as a
low collar curvilinear insicion
MODIFIED RADICAL MASTECTOMY
o Incision chosen that would have the least
tension on closure, either elliptical, vertical
o Using a sterile marking pen, circle drawn 23 cm away from the perimeter of the
primary tumor. In addition to the area of skin
outlined by the circle drawn around the
tumor include the entire areola and nipple in
the patch of skin left on the specimen.
o Sterile drapes placed
o Asepsis/ Antisepsis done
o Patient positioned with ipsilateral arm
abducted in 90 on an arm board and place a
folded sheet, about 5 cm thick under the
patients scapula and posterior hemithorax
etc.
o Dry sterile dressing
o Two Jackson-pratt drains placed; the first to
drain the inferior skin flap and the axilla,
and second to drain the superior skin flap.
Close the subcutaneous tissue with
interrupted 3-0 vicryl and close the skin with
vicryl 4-0 subcuticularly
o Complete count
o Irrigation
o Hemostasis
o Five nerves should be identified and
protected if possible

o long thoracic nerve- innervating the

serratus anterior muscles, if injured caused
winged
deformity
o thoracodorsal nerve- innervates the
latissimus dorsi muscle
o medial anterior thoracic-lateral to the
pectoralis minor muscle
o lateral anterior thoracic-medial edge of the
pectoralis minor
o subscapular
o Using a scalpel or metzenbaum scissors,
axillary contents of fat and lymph nodes
evacuated, pushing them towards the breast
in continuity
o Brachial plexus and axillary artery
protected
o Axillary vein and its tributaries identified.
Ligation of all the tributaries toward the
breast with 3-0 or 4-0 silk.
o The clavipectoral fascia opened, for access
to the axilla. Pectoralis major and minor
protected.
o Arterial perforators entering the breast
ligated with vicryl 2-0
o Dissection of the breast began medially.
Pectoralis fascia elevated
o Use electrocautery for the formation of the
upper and lower flaps
o Hemostasis obtained by applying
electrocoagulation to each bleeding point
o Incision made through all the layers of the
skin
TOTAL MASTECTOMY
o Same as modified radical mastectomy
without the axillary dissection
WIDE EXCISION WITH AXILLARY DISSECTION
o Wound closure
o Complete count
o Hemostasis
o Axillary cavity drained with Jackson pratt
o Dissection completed and specimen
separated from the axillary vein.
o Thoracodorsal nerve protected, identified
closed to the ant margin of the latissimus

dorsi muscle and the long thoracic nerve,

under the fascia of the serratus anterior
muscle.
o Axillary vein identified at the medial area of
the pectoralis minor and tributaries ligated.
o Both pectoralis muscles retracted.
o Transverse incision at the lower axilla.
o cosmetic incision elliptical incision. Remove
the tumor and healthy mammary tissue and
send it to lab for frozen section
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
EXCISION OF BRANCHIAL CLEFT CYST
o WOUND CLOSURE
o CORRECT COUNT
o LAVAGE or IRRIGATION
o HEMOSTASIS
o dissection of the cyst or sinus cephalad
toward the pharyngeal wall
o carotid sheat and hypoglossal nerve
visualized
o sternocleidomastoid muscles separated
and elevated, always using the medial border
o Multiple incisions if the cyst or sinus is low
o A small transverse incision done above the
cyst; around a sinus an elliptical incision
made.
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine, head turned to the
contralateral side with neck hyperextended
EXCISION OF THE THYROGLOSSAL DUCT CYST
o HEMOSTASIS
o Foramen cecum excised in continuity and
the defect closed with figure-of-eight 4-0
chromic catgut or any other absorbable
suture.
o The foramen cecum also requires special
attention. The anesthesiologists index finger
is
inserted into the patients mouth, elevating
the foramen cecum. With continous
cephalad dissection, one reaches the foramen
cecum by palpating the finger of the

anesthesiologist just under the thyrohyoid

membrane.
o Thyrohyoid membrane now exposed
o Upward dissection continued bilaterally to
the midline where the tract is located
o Curved hemostat inserted under the central
part of the hyoid bone. With heavy scissors
or small bone cutter, bone cut on both sides.
o Some cuffs of sternohyoid and mylohyoid
left attached to the bone, as well as some
cuffs of the underlying geniohyoid and
genioglossus attached to the cephalad tract.
o Central part of the hyoid bone cleaned.
o Special care taken of the hyoid bone and
tract.
o Cyst dissected and isolated with a small
hemostat and scissor. The involved anatomical
entities depend upon the location of the cyst:
suprahyoid (rare), hyoid (common),
infrahyoid or suprasternal (rare).
o Lower flap elevated almost to the isthmus
of the thyroid gland
o Formation of the flaps: the upward
elevation reaching the hyoid bone and
extending
cephalad 1-2 cm.
o superficial fascia (fat and platysma) incised
o transverse incision over the cyst.
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine with neck hyperextended
o WOUND CLOSURE
o Reconstruction. Midline approximation
performed of the mylohyoid and sternohyoid
with interrupted sutures
o CORRECT COUNT
o LAVAGE or IRRIGATION
EXCISION OF CYSTIC HYGROMA
o WOUND CLOSURE
o CORRECT COUNT
o DRAIN (rational placement)
o LAVAGE or IRRIGATION
o HEMOSTASIS
o Extensions into various tissue planes and
between muscle and nerve bundles, followed,

exposed and removed to effect a complete

cure
o Careful sharp dissection, usually employing
a no. 15 blade supplemented with blunt
dissection
o Sharp and blunt dissection upward, and
downward
o Skin and fat carefully elevated using a knife
o Adequate transverse incision above the cyst
o Patient supine, head turned to the
contralateral side
TRACHEOSTOMY
o Iodoform packed in the subcutaneous
tissue around the tracheostomy tube
o The tube secured with umbilical tape
around the patients neck.
o correct count
o Hemostasis
o Hardy-shiley tracheostomy tube inserted as
the endotracheal tube is slowly backed out
o tracheal opening widened with a tracheal
spreader
o cricoid cartilage and 1st tracheal ring
prtected to avoid postoperative tracheal
stenosis
o vertical incision through the 2-3 tracheal
ring.
o anterior tracheal wall mobilized and
elevated using a hook at the lower border of
the
cricoid cartilage
o anterior wall of the trachea below the
isthmus cleaned
o thyroid isthmus and thyroidea ima
identified & ligated
o extended to expose the full length of the
strap muscles
o incision through the cervical fascia in the
midline,
o adult: vertical or transverse incision
o children: vertical incision to avoid injury of
the arteries and veins located
under the anterior border of SCM
o Incision two finger breadths above the
sternal notch

o Asepsis-antisepsis
o Patient supine with neck hyperextended
RIGHT HEMICOLECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to
peritoneum
o Exploration of the entire peritoneal cavity
o Mobilization of the right colon by incision of
the right paracolic peritoneal
reflection from distal ileum
o down to the transeverse colon.
o Renocolic and hepatocolic ligaments
divided
o Duodenum protected
o gonadal vessels separated and right ureter
identified
o Lines of resection identified
o Terminal ileum and transverse colon
occluded with umbilical tape.
o ileocolic pedicle ligated.
o right branch of middle colic pedicle ligated
o distal ileum and transverse colon divided
just after the hepatic flexure
o viability of the cut segments checked
o Bowel edges painted with betadine
o Resection of the mesentery down to the
root
o Two- layer end to end anastomosis
(ileocolic) using an interrupted silk 4-0
(Connel technique) and interrupted silk 4-0
(Lembert technique) for the
seromuscular layer
o Anastomosis checked for leakage
o mesenteric decfect clsoed with Chromic 2-0
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Skin Silk 4-0
LEFT HEMICOLECTOMY
o Patient supine

o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to
peritoneum
o Exploration of the entire peritoneal cavity
o left colon from sigmoid to left transverse
colon mobilized by incising the
peritoneal reflection of the left paracolic
gutter.
o Splenocolic, renococolic and
pancreaticocolic ligaments divided
o Gonadal vessels separated and left ureter
identified
o Distal transverse colon and sigmoid colon
occluded with umbilical tape
o Ligation the inferior mesenteric artery at its
take off from the aorta and
the inferior mesenteric vein
o Lines of resection identified
o proximal sigmoid divided followed by the
left transverse colon just
before the splenic flexure
o viability of the cut segments checked
o Bowel edges painted with betadine
o Resection of the mesentery down to the
root
o Two- layer end to end anastomosis using an
interrupted silk 4-0 (Connel
technique) and interrupted silk 4-0 (Lembert
technique) for the
seromuscular layer
o Anastomosis checked for leakage
o Mesenteric defect closed with chromic 3-0
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Skin Silk 4-0
TRANSVERSE COLECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed

o Midline incision carried down from skin to

peritoneum
o Exploration of the entire peritoneal cavity
o Gastrocolic ligament releasedfrom the
hepatic to splenic flexure
o Hepatic and splenic flexure released
o Transverse colon occluded with umbilical
tape
o Middle colic artery and vein ligated
o Lines of resection identified
o Transverse colon divided at the hepatic and
splenic flexure
o Viability of the cut segments checked
o Bowel edges painted with betadine
o Resection of the mesentery down to the
root
o Two- layer end to end anastomosis using an
interrupted silk 4-0 (Connel
technique) and interrupted silk 4-0 (Lembert
technique) for the
seromuscular layer
o Anastomosis checked for leakage
o Mesenteric decfect closed
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Skin Silk 4-0
SIGMOID COLECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Low midline incision carried down from
skin to peritoneum
o Exploration of the entire peritoneal cavity
o Left colon carefully mobilized from
rectosigmoid to descending colon by
incising the peritoneal reflection of the
paracolic gutter
o Splenocolic and renocolic ligaments divided
o Gonadal vessels separated and left ureter
identified
o Sigmoid colon occluded with umbilical tape

o Incision made at the right side of the

sigmoid mesocolon down to the
distal sigmoid
o Inferior mesenteric artery ligated just after
take off from the aorta and
the inferior mesenteric vein
o Lines of resection identified
o proximal sigmoid divided followed by the
distal sigmoid
o Bowel edges painted with betadine
o Check for the viability of the cut segment
o Resection of the mesentery down to the
root
o Two- layer end to end anastomosis using an
interrupted silk 4-0 (Connel
technique) and interrupted silk 4-0 (Lembert
technique) for the
seromuscular layer
o Anastomosis checked for leakage
o Mesenteric decfect closed
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Skin Silk 4-0
o Dry sterile dressing
ANTERIOR RESECTION
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Low midline incision carried down from
skin to peritoneum
o Exploration of the entire peritoneal cavity
o Mobilization of the left colon from
descending to rectosigmoid colon by
incision of the peritoneal reflection of the left
paracolic gutter down to
the sacral promontory
o gonadal vessels separated and left ureter
identified
o dissection continued to the rectovesical
space

o right ureter identified by an incision at the

right side of the sigmoid
mesocolon down to rectovesical pouch
o inferior mesenteric artery ligated just after
take off from the aorta and
the inferior mesenteric vein
o Lines of resection identified
o Divide the proximal sigmoid followed by the
rectosigmoid segment
o Bowel edges painted with betadine
o viability of the cut segment checked
o Resection of the mesentery down to the
root
o Two- layer end to end anastomosis using an
interrupted silk 4-0 (1st
layer) and interrupted silk 4-0 (Lembert
technique) for the seromuscular
layer
o Anastomosis checked for leakage
o mesenteric defect closed
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Skin Silk 4-0
TOTAL COLECTOMY
o Patient supine
o Sterile field prepared
o Midline incision carried down from skin to
peritoneum
o Exploration of the entire peritoneal cavity
o Mobilization the right colon by incising the
right paracolic peritoneal
reflection from distal ileum down to the
transverse colon.
o Right renocolic and hepatocolic ligaments
divided
o Duodenum protected
o gonadal vessels separated and right ureter
identified
o Mobilization the left colon from sigmoid to
left transverse colon by

incising the peritoneal reflection of the left

paracolic gutter.
o Division of the splenocolic, renococolic and
pancreaticocolic ligaments
o gonadal vessels separated and left ureter
identified
o gastrocolic ligament released
o hepatic and splenic flexure released
o Ligation of the lymphovascular pedicles
starting from the ileocolic, right
colic, middle colic and inferior mesenteric
vessels
o Mesenteric dissection
o Mobilization of distal part downward to the
sacral promontory and the
pre-sacral area
o Lines of resection identified
o Distal ileum transected followed by
transaction ofthe proximal rectum
o Two- layer end to end anastomosis
(ileorectal) using an interrupted silk 40 (1st layer) and interrupted silk 4-0 (Lembert
technique) for the
seromuscular layer
o Anastomosis checked for leakage
o mesenteric defect closed
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Skin Silk 4-0
TRANSVERSE/ SIGMOID LOOP COLOSTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Transverse incision over right or left upper
quadrant for transverse and
left lower quadrant for sigmoid
o Division of the anterior rectus sheath
o rectus abdominis muscles retracted
o posterior rectus sheath and peritoneum
divided

o Exteriorization of transverse/sigmoid colon

into the wound
o exteriorized bowel sutured to the fascia
with silk 4-0
o small hole created at the mesenteric border
of the colon and plastic rod
inserted
o colon opened and matured to the skin with
4-0 vicryl sutures
o Cover the colostomy with wet gauze
CLOSURE OF COLOSTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile field prepared
o Colostomy occluded with gauze
o Elliptical incision around the colostomy
o Mobilization of the colostomy from
subcutaneous fat down to fascial
attachments
o Peritoneal cavity opened
o colon released from adhesions in the
peritoneal cavity
o colon debrided or resected if needed
o Two- layer anastomosis using an
interrupted silk 4-0 (1st layer) and
interrupted silk 4-0 (Lembert technique) for
the seromuscular layer
o Anastomosis checked for leakage
o Hemostasis
o Complete count
o Wound closure
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Subcutaneous tissue and skin - open
ABDOMINOPERINEAL RESECTION
o Patient supine in the lithotomy position
o Anus is closed with silk 0 suture
o Sterile field prepared
o Low midline incision carried down to
peritoneum
o Exploration of entire peritoneal cavity
o Mobilization of the sigmoid & descending
colon by incising the peritoneal
reflection of the left paracolic gutter

o Gonadal vessels separated and left ureter

identified
o Mobilization of distal part downward to the
sacral promontory and the
pre-sacral area
o dissection to the rectovesical space
continued
o incision made at the right side of the
sigmoid mesocolon down to
rectovesical pouch and right ureter identifed
o Proximal sgmoid occluded with umbilical
tape
o Ligation of inferior mesenteric artery, just
after take off from the aorta
and the inferior mesenteric vein
o The lymphatic tissue in the pelvis removed
with the specimen
o Sharp and blunt dissection of the rectum
up to the level of the tip of the
coccyx
o Lateral stalks divided, and ligated with 2-0
silk sutures
o Lines of resection identified
o Sigmoid colon transected, both cut ends
closed to prevent spillage
o Colostomy site prepared
PERINEAL DISSECTION:
o Skin Silk 4-0
o Peritoneum and fascia Vicryl 0 continuous
interlocking suture
o Closure layer by layer
o Complete count
o Peritoneal washing
o peritoneum in the pelvic area closed
o Hemostasis
o Colostomy matured to the skin
o Skin closed with simple interrupted sutures
o Perineum packed with gauze inside a glove
o Washing with NSS
o Hemostasis
o prostate gland / posterior vaginal wall can
be included in the specimen if
necessary
o Anterior part of the perineal dissection
carried out

o transected sigmoid specimen delivered

through the perineal opening
o levator muscles opened upward beginning
from below up to the region of the
puborectalis sling
o Inferior and middle hemorrhoidal vessels
ligated
o Sharp division of Waldeyers fascia
o anococcygeal ligament cut with cautery
o perirectal fat incised down to the levator
diaphragm
o Incision carried into perirectal fat
o Elliptical incision 3-4 cm anterior to the anal
orifice and terminating at the tip of coccyx
HEMORRHOIDECTOMY
o Light dressing
o Achieve complete hemostasis
o hemorrhoidal pedicle oversewn with a
running lock-stitch of chromic 2-0 until entire
defect has been closed
o hemorrhoidal mass dissected and divided
with electrocautery
o Hemorrhoid drawn away from the
sphincter with blunt dissection
o Submucosal dissection of hemorrhoidal
tissue down to the internal sphincter muscle
o elliptical incision over anoderm including
skin tag made
o Suture ligation of feeding vessel
o hemorrhoids with hemorrhoidal clamp
o hemorrhoids identified
o gauze sponge inserted into the lower
rectum
o anal dilatation and anoscopic evaluation
performed
o Sterile field prepared
o Patient in a lithotomy position
FISTULOTOMY/FISTULECTOMY
o Dry sterile dressing
o Hemostasis
o All tracts kept fully opened
o soft tissues overlying the tract divided and
part of the margin excised to
convert the deep slit-like defect into a Vshaped defect

o probe inserted into fistulous tract while

anal canal palpated to identify the external
opening
o external openings of the fistula identified
o anal dilatation and anoscopic evaluation
performed
o Sterile field prepared
o Patient in a lithotomy position
APPENDECTOMY
o Dry sterile dressing
o Skin with silk 4-0
o Fascia with Vicryl 0 continous interlocking
o Peritoneum with vicryl 0 continous
interlocking
o Close abdominal wall in layers
o Complete instrument and sponge count
o Hemostasis
o Stump painted with Betadine
o Base tied with Cotton 2-0
o Mesoappendix serially clamped, cut and
ligated.
o Appendix grasped with Babcock
o Cecum identified and anterior taenia traced
up to the base of appendix
o Bowels retracted
o Wet gauze applied on subcutaneous tissue
o Peritoneum grasp with hemostats and
opened.
o Muscle splitting done
o Fascia cut obliquely
o Transverse incision at the right lower
quadrant carried down from skin up to
subcutaneous tissue
o Sterile field prepared
o Asepsis-antisepsis
o Patient supine
OPEN CHOLECYSTECTOMY
o Sterile field prepared
o Asepsis-antisepsis observed
o Patient supine with padding at the
posterior right upper quadrant
o Dry Sterile Dressing
o Skin closed subcuticularly using vicryl 4-0.
o Ant.rectus sheath and fascia - continuos
interlocking -Vicryl-0

o Peritoneum and post.rectus sheath continuos interlocking -Vicryl-0

o Layer by layer closure
o Complete count
o Hemostasis done
o Irrigation with NSS
o Cystic duct is ligated with silk 2-0 suture
close to the common bile duct
o Sharp dissection done to release the
gallbladder from the liver bed from fundus
down
the cystic duct
o Cystic artery identified and ligated
o Dissection is continued along the same fold
of visceral peritoneum upward
o Cystic duct identified, traction suture
applied to prevent passage of stone
o Blunt dissection towards the cystic duct
o Visceral peritoneum at the hepatoduodenal
ligament opened
o Gallbladder is grasp with forceps at fundus
o Intraoperative findings noted
o Oblique right subcostal incision, carried
down to peritoneum
CHOLECYSTECTOMY, IOC, CBD
EXPLORATION,T-TUBE CHOLEDOCHOSTOMY
o Dry Sterile Dressing
o Skin closed subcuticularly using vicryl 4-0.
o Ant.rectus sheath and fascia - continuos
interlocking -Vicryl-0
o Peritoneum and post. rectus sheath continuos interlocking -Vicryl-0
o Layer by layer closure
o T-tube is brought out thru a separate stab
wound
o Complete count
o Hemostasis done
o Irrigation with NSS
o Completion cholangiogram done to confirm
the absence of stones
o Saline is injected to Ttube to check for
leaks
o Choledochotomy is closed around the Ttube
o T-tube is inserted with limbs cut short

o No.3 Bakes dilator is passed in the distal

CBD and the tip is visualized thru the anterior
wall of the duodenum
o CBD stones removed using Randall forceps
o Irrigation with saline done proximally and
distally to flush the stones out
o Vertical incision is made between the
sutures
o Traction suture placed laterally and
medially using silk 4-0
o Site of choledochotomy identified and
skeletonized
o Palpate the CBD, pancreas and duodenum
o Perform Kocher maneuver (release the
lateral and posterior attachments of the 2nd
portion of duodenum)
o Perform transcystic intra-op cholangiogram
CHOLECYSTECTOMY (same procedure):
o Intraoperative assessment
o
o Oblique right subcostal incision, carried
down to peritoneum
o Sterile field prepared
o Asepsis-antisepsis observed
o Supine with padding at the posterior right
upper quadrant
CHOLEDOCHODUODENOSTOMY
o Dry Sterile Dressing
o Subcutaneous closed by inverted T sutures
using Chromic 2-0
o Ant.rectus sheath and fascia - continuos
interlocking -Vicryl-0
o Peritoneum and post.rectus sheath continuos interlocking -Vicryl-0
o Layer by layer closure
o Place a drain
o Complete count
o Hemostasis done
o Irrigation with NSS
o Check for anastomtic leak
o Side to side anastomosis in a single layer
using interrupted silk 4-0
o Make a transverse incision to the
duodenum near to the CBD incision

o Anchor the duodenum to the CBD by

placing a row of silk 4-0 sutures
posteriorly
o Mobilize the CBD and duodenum
adequately
o CBD Exploration
o Vertical incision is made between the
sutures
o Traction suture placed laterally and
medially using silk 4-0
o Site of choledochotomy identified and
skeletonized
o Palpate the CBD, pancreas and duodenum
o Perform Kocher maneuver (release the
lateral and posterior attachments of the 2nd
portion of duodenum)
CHOLECYSTECTOMY (same procedure):
o Intraoperative findings noted
o Oblique right subcostal incision (may
extend to the left chevron incision) carried
down
to peritoneum
o Sterile field prepared
o Asepsis-antisepsis observed
o Patient supine with padding at the
posterior right upper quadrant
CHOLECYSTOJEJUNOSTOMY
o Anchor the jejunum to the fundus of
gallbladder
o Identify the jejunal site for anastomosis
about 30 cms from the ligament
of Treitz
o Open the gallbladder transversely and
assess the patency of the cystic duct, remove
any
stone
o Intraoperative findings noted
o Oblique right subcostal incision(may extend
to the left chevron incision) or midline
incision carried down to peritoneum
o Sterile field prepared
o Asepsis-antisepsis observed
o Supine with padding at the posterior right
upper quadrant
o Dry Sterile Dressing

o Skin closed subcuticularly using vicryl 4-0.

o Ant.rectus sheath and fascia - continuos
interlocking -Vicryl-0
o Peritoneum and post.rectus sheath continuos interlocking -Vicryl-0
o Layer by layer closure
o Insert a drain
o Complete count
o Hemostasis done
o Irrigation with NSS
o Check for anastomtic leak
o Perform the anastomosis in a single layer
using interrupted silk 4-0
sutures
o Make a transverse incision on the jejunum
SPHINCTEROTOMY / SPHINCTEROPLASTY
o Dry Sterile Dressing
o Skin closed subcuticularly using vicryl 4-0.
o Ant.rectus sheath and fascia - continuos
interlocking -Vicryl-0
o Peritoneum and post.rectus sheath continuos interlocking -Vicryl-0
o Layer by layer closure
o Place a drain
o Close the CBD over a T-tube
o Close the duodenum in 2 layers using silk 0
o Hemostasis
o Protect the pancreatic duct opening
o Suture the ductal and duodenal mucosa
with interrupted 5-0 synthetic
absorbable sutures
o Perform 5 mm sphincterotomy between the
10 and 11 o clock positions
using scalpel blade or a potts scissor
o At the 3 and 9 o clock positions in the
periampullary area, place 5-0 silk
stay sutures
o Locate the ampulla
o Perform duodenotomy - vertical incision at
the anti-mesenteric side
o Place stay sutures of silk 4-0 at the
duodenotomy site
o Identify the duodenotomy site by passing
bakes dilator into the CBD
down as guide to the location of the ampulla.

o Carry out choledochotomy.CBDE

o Palpate the CBD, pancreas and duodenum
o Perform Kocher maneuver (release the
lateral and posterior attachments of the 2 nd
portion of duodenum)
o Perform IOC
CHOLECYSTECTOMY (same procedure)
o Intraoperative assessment
o Oblique right subcostal incision(may extend
to the left chevron incision) carried down
to peritoneum
o Sterile field prepared
o Asepsis-atnisepsis technique observed
o Patient supine with padding at the
posterior right upper quadrant
DISTAL PANCREATECTOMY
o Dry Sterile Dressing
o Skin closed subcuticularly using vicryl 4-0.
o Subcutaneous closed by Inverted T sutures
using Chromic 2-0
o Ant.rectus sheath and fascia - continuos
interlocking -Vicryl-0
o Peritoneum and post.rectus sheath continuos interlocking -Vicryl-0
o Layer by layer closure
o Insert a drain (close suction drain)
o Complete count
o Hemostasis done
o Irrigation with NSS
o Close the cut edge with interrupted sutures
silk 3-0
o Identify the pancreatic duct and close with
mattress suture.
o Transect the pancreas
o Identify the site of resection
o Mobilize the inferior border of pancreas
extending posteriorly
o Mobilize the pancreas by incising the
peritoneum on the superior
border, protect the splenic artery
o Release the tail from the spleen and
develop a plane in between
o Assess the extent of the resection
o Assess the entire pancreas

o Retract the stomach upward, and the

transverse colon downward
o Open the entire lesser sac by releasing the
gastrocolic ligament
o Palpate the entire abdomen
o Midline incision or oblique left subcostal
incision extended to the right and carried
down to peritoneum
o Sterile drapes placed
o Asepsis-antisepsis technique observed
o Patient supine
WHIPPLES PROCEDURE
o Distal CBD transected near duodenum
o cholecystectomy done
o right gastric artery identified and ligated
o gastroduodenal artery identified and
ligated
o distal CBD exposed
o Hepatic artery identified and skeletonized
o Extensive Kocher maneuver done from
foramen of Winslow superiorly
up to as far as the point where SMV crosses
the transverse (3rd
portion) duodenum
o Dissection of portal vein and superior
mesenteric vein
o Resectability assessed
o Intaoperative findings noted
o Midline incision carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsiis-antisepsis
o Patient supine
o Layer by layer closure
o Complete count
o Hemostasis
o Peritoneal washing
o Drains inserted over hepatico-J and
pancreatico-J anastomosis
o Tube jejunostomy inserted
o Jejunojejunostomy (2 layer)
o Gastrojejunostomy using a Roux en Y
technique (2 layer)
o End to side hepaticojejunal anastomisis
about 8 cms away from

pancreatico-jejunal anastomisis (2 layer

technique)
o End-to-end pancreatico-jejunal anastomosis
by invagination done with a feeding tube
inserted into the pancreatic duct and exit into
the jejunum 30 cms away, along
antimesenteric wall and brought out thru the
skin (2-layer technique)
o Dissection and Division of Proximal Jejunum
o Uncinate process divided with
electrocautery, edges sutured using
continuous interlocking technique with silk 4-0
o Ligation of the superior and inferior
pancreatic artery
o Neck and the body of the pancreas freed
from underlying splenic vein
from above
o Division of Pancreas about 3 cms from left
of SMV
o stomach transected
o Identify site of gastric transection
o Ligate the gastroepiploic arcade along
greater curvature of stomach
o Left gastric artery identified and ligated
o Gastric dissection
SPLENECTOMY
o Dry sterile dressing
o Skin Silk 4-0
o Fascia - continuous interlocking suture
using Vicryl 0
o Abdominal closure
o Correct count
o Irrigation done
o Hemostasis
o spleen removed, small feeding vessels
ligated
o the tail of the pancreas protected
o Individual ligation of the splenic vessels
done
o hilum dissected
o short gastric vessels ligated
o splenophrenic, splenorenal and splenocolic
ligaments ligated
o spleen mobilized

o splenic artery identified and ligated

proximally
o gastrocolic omentum opened
o Intraoperative findings noted
o Midline incision carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
PORTOCAVAL SHUNT
o Dry sterile dressing
o Skin Silk 4-0
o Fascia - continuous interlocking suture
using Vicryl 0
o Abdominal closure
o Correct count
o Irrigation done
o Hemostasis
o Anastomose the portal vein to the inferior
vena cava using 6-0
polypropylene continuous suture
o Oversew the hepatic portal stump with 5-0
polypropylene
o Divide the portal vein near the hepatic side
(if end to side)
o Runnjing 4-0 vascular suture used for the
anastomosis
o A side to side anastomosis or end to side
portocaval shunt performed
o IVC skeletonized
o Mobilization of the inferior vena cava by
reflecting the duodenum to the
left (Kocher maneuver)
o Isolation and mobilization of the portal vein
o Portal triad exposed
o Intraop findings noted
o Midline incision carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsis-antisepsis observed
o Patient supine
SPLENORENAL SHUNT
o the distal end to side of the left renal vein
anastomosed using

o the hepatic end of the splenic vein

oversewn
o the splenic vein divided at the junction with
the superior mesenteric vein.
DISTAL SPLENORENAL SHUNT:
o Retroperitoneal dissection, left renal vein
isolated and mobilized from
the inferior vena cava to the hilum of the
kidney
o Splenic vein mobilized, small tributary veins
ligated
o Incise the peritoneum in the inferior
surface of the pancreas and
upwardly retract the body of the pancreas
o Preserve the short gastric vessels to the
hilum of the spleen
o Divide the greater omentum between the
greater curvature of the
stomach and the transverse colon
o Retract the small bowel forward and to the
right
o Mobilize the transverse colon down to the
splenic flexure and proximal
descending colon
o Intraop evaluation made
o Midline incision or bilateral subcostal
approach carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsis-antisepsis observed
o Patient supine
continuous 6-0 polypropylene
o Dry sterile dressing
o Skin Silk 4-0
o Fascia - continuous interlocking suture
using Vicryl 0
o Abdominal closure
o Correct count
o Irrigation done
o Hemostasis
o Ligation of the left gastric (coronary) vein
and the right gastroepiploic
vein
o Anastomosis of the proximal end to side of
the left renal vein done using

continuous 6-0 polypropylene

o the splenic end of the splenic vein
oversewn
o splenic vein divided near the hilum of the
spleen
PROXIMAL SPLENORENAL SHUNT:
HEPATIC RESECTION (RIGHT LOBECTOMY)
o Layer by layer closure
o Suction drain placed
o Hemostasis and bile stasis
o right lobe of liver removed
o Parenchyma of caudate process transected
to expose the anterior surface of the inferior
vena cava
o Middle hepatic vein ligated during the
parenchymal resection
o Smaller bile ducts & vessels ligated on the
resected side of liver
o Parenchyma transected on the line of
vascular demarcation
o right hepatic vein transected with running
silk 1-0 suture
o Main right hepatic vein is dissected from
the inferior vena cava and liver
o retrocaval ligament bridging segments 1
and 7 divided
o main right hepatic vein exposed
o Multiple small short hepatic veins between
inferior vena cava and segments 1, 6, and 7 a
are ligated
o Right lobar portal vein branch freed from
surrounding lymphoareolar tissue and ligated
o Right portal vein exposed from right of the
hepatoduodenal ligament
o portal vein bifurcation exposed
o Lymphatic vessels around hepatic artery
ligated
o Right hepatic artery doubly ligated with silk
1-0 and divided
o Hepatoduodenal ligament incised
longitudinally posterior to the bile duct
RIGHT LOBECTOMY:
o cholecystectomy done
o the gastrohepatic omentum divided

o ligamentum teres hepatis and falciform

ligament divided
o the liver mobilized from the hepatic flexure
o Intraoperative evaluation
o Bilateral oblique subcostal incision
(chevron) carried down to peritoneum
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
INGUINAL HERNIORRHAPHY
o Dry sterile dressing
o Skin - subcuticular with vicryl 4-0
o Closure of the external oblique aponeurosis
with vicryl 2-0 continous
interlocking
o Wound closure
o Complete count
o Hemostasis
o conjoined tendon sutured to the inguinal
ligament (shelving edge) from
pubis to internal ring
o Distal part of the sac left open after
hemostasis
o High ligation of the proximal sac
o Reduction of content
o Proximal part is dissected up to the internal
ring and laterally to the deep
epigastric vessels
o hernial sac skeletonized, opened, and
transected
o sac located anterior to the spermatic cord
o spermatic cord isolated and retracted with
an umbilical tape
o ilioinguinal nerve identified and spared
o external oblique aponeurosis opened along
its fibers down to the eternal
ring
o Large veins ligated ( superficial epigastric )
o Incision carried down to fascia
o Oblique inguinal incision parallel to the
inguinal ligament
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
HERNIOPLASTY

o Prolene mesh, placed under spermatic

cord, 3-4 cm larger than the
o Distal part of the sac left open after
hemostasis
o High ligation of the proximal sac
o Proximal part dissected up to the internal
ring and laterally to the deep
epigastric vessels
o Hernial sac skeletonized, opened, and
transected
o Hernial sac located anterior to the
spermatic cord
o spermatic cord isolated and retracted with
umbilical tape
o ilioinguinal nerve identified and spared
o external oblique aponeurosis opened along
its fibers down to the eternal
ring
o Large veins ligated ( superficial epigastric )
o Incision carried down to fascia
o Oblique inguinal incision parallel to the
inguinal ligament
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
defect circumferentially
o Dry sterile dressing
o Skin - subcuticular with vicryl 4-0
o Close the external oblique aponeurosis with
vicryl 2-0 continuous
interlocking
o Wound closure
o Correct count
o Hemostasis
o Cut the mesh and snug cut edge to the
spermatic cord
o Prolene mesh sutured with silk 2-0 with
interrupted mattress around the
perimeter, anterior rectus sheath, rectus
muscle, and transversalis fascia
along medial aspect and to the inguinal
ligament laterally
oooo
REPAIR OF UMBILICAL HERNIA
o Dry sterile dressing

o skin - silk 3-0 simple interrupted

o subcutaneous tissue - chromic 2-0 simple
interrupted
o Wound closure
o Drain if needed
o Correct count
o Hemostasis
o Primary closure of the fascia using Vicryl 0
continuous interlocking with
interrupted silk 0
o hernial sac removed
o Reduction of hernial sac contents into the
abdominal cavity
o hernial sac then opened, adhesions
released intraperitoneally
o entire circumference of the defect exposed
o The hernial sac identified and dissected
towards the fascial defect
o Curved infraumbilical incision carried down
to subcutaneous tissue
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
Billroth I
o Dry sterile dressing
o Skin Silk 4-0
o Fascia - continuous interlocking suture
using Vicryl 0
o Abdominal closure
o Correct count
o Irrigation done
o Hemostasis
o Anastomosis reinforced with omentum
o A 3 suture bites at the lesser curvature area
placed ( anterior stomach,
posterior stomach and duodenum) using silk
3-0
o Anastomosis of the gastric opening to the
duodenum (2 layers) using
chromic 3-0 continuous as first layer followed
by 3-0 silk interrupted as
2nd layer
o Partial closure of the gastric opening at the
lesser curvature (2 layers)

using chromic 3-0 continuous as first layer

followed by 3-0 silk
interrupted as 2nd layer
o Duodenum transected just below the
pyloric ring
o Stomach transected over a clamp
o Line of gastric transection identified
o dissection continued toward the left gastric
artery
o right gastric artery ligated
o vessels of the lesser curvature ligated
o dissection carried out to the
gastroduodenal area , small feeding vessel
ligated
o gastroepiploic vessels ligated
o gastrocolic ligament incised and transverse
colon retracted downward
o Ligation of arteries and veins of the greater
curvature distal to the point
of the gastric transection
o Mobilize the distal stomach
o Intaoperative findings noted
o Midline incision carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
SUBTOTAL DISTAL GASTRECTOMY (Billroth II)
o gastric opening anastomosed to the loop of
jejunum (2 layers) using a running
o Proximal jejunal loop brought up in an
antecolic fashion
o Partial closure of the gastric opening at the
lesser curvature side
o Duodenal stump iclosed in two layers with
chromic 3-0 and silk 3-0
o specimen removed
o Duodenum transected just below the
pyloric ring
o Stomach transected over a clamp
o Line of gastric transection identified
o dissection continued toward the left gastric
artery
o right gastric artery ligated
o vessels of the lesser curvature ligated

o dissection to the gastroduodenal area

carried out , small feeding vessel ligated
o gastroepiploic vessels ligated
o gastrocolic ligament incised and transverse
colon retracted downward
o arteries and veins of the greater curvature
distal to the point of the gastric
transaction ligated
o Distal stomach mobilized
o Intaoperative findings noted
o Midline incision carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
3-0 chromic for the mucosa and interrupted 30 silk seromuscular
o Dry sterile dressing
o Skin Silk 4-0
o Fascia - continuous interlocking suture
using Vicryl 0
o Abdominal closure
o Correct count
o Irrigation done
o Hemostasis
TOTAL GASTRECTOMY
o Dry sterile dressing
o Skin Silk 4-0
o Fascia - continuous interlocking suture
using Vicryl 0
o Abdominal closure
o Correct count
o Irrigation done
o Hemostasis
o opening of the proximal jejunum
anastomosed to the jejunal loop in two
layers (end to side)
o end to side or end to end anastomosis with
2 layer sutures
o distal end to the esophageal stump
elevated without tension
o proximal jejunum divided about 15 cms
from ligament of Treitz
o A roux en Y esophagojejunal anastomosis
performed

o stomach removed
o abdominal esophagus divided, stay sutures
placed on each side of the
esophagus
o Duodenal stump closed in two layers with
chromic 3-0 and silk 3-0
o duodenum divided
o entire stomach mobilized from the
gastroesophageal junction to the
proximal portion of the duodenum
o right and left gastric arteries ligated
o lesser omentum opened and removed
o short gastric vessels ligated
o right and left gastroepiploic vessels ligated
o upward dissection of the greater omentum
continued
o greater omentum separated from the
transverse colon
o gastroesophageal area released and
abdominal esophagus mobilized
o Intaoperative evaluation for operability
o Midline incision carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
VAGOTOMY
o Intraoperative evaluation
o Midline incision carried down from skin to
peritoneum
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
TRUNCAL VAGOTOMY
o (Right) posterior vagus nerve palpated and
identified, segment of the
nerve removed, the proximal and distal ends
ligated
o (Left) anterior vagus nerve identified & a
segment of the nerve removed,
proximal and distal ends ligated
o anterior esophagus skeletonized
o peritoneum incised at the gastroesophageal
junction
o abdominal esophagus

PROXIMAL GASTRIC VAGOTOMY

o Dry sterile dressing
o Skin Silk 4-0
o Fascia - continuous interlocking suture
using Vicryl 0
o Abdominal closure
o Correct count
o Irrigation done
o Hemostasis
o Re-peritonealization of the lesser curve
done
o Dissection continued toward the incisura
angularis
o Starting approximately 6 cm from the
pylorus, the neurovascular
elements were divided and ligated between
the inner curve and the
nerve of Laterjet
o distal half of the lesser curvature mobilized
o nerves of Laterjet localized, hepatic and
celiac divisions protected
o right and left vagus nerves identified
o abdominal esophagus mobilized
PYLOROPLASTY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to
peritoneum
o Intraoperative evaluation
HEINEKE-MIKULICZ technique
o Pyloric area identified
o longitudinal pyloroduodenal incision about
5cm in length
o Wound closed transversely in 2 layers using
3-0 absorbable suture and 30 silk
FINNEY technique
o Pyloric area mobilized down to the 2nd
portions of the duodenum
o site for pyloroduodenal incision identified
o pyloric area of the stomach sutured to the
1st portion of the duodenum
with interrupted lembert suture using 3-0 silk,

o U shaped pyloroduodenal incision made

including the distal pyloric
antrum and the proximal 2nd portion of the
duodenum
o Gastroduodenal opening closed in 2 layers
o Hemostasis
o Irrigation done
o Correct count
o Abdominal closure
o Fascia - continuous interlocking suture
using Vicryl 0
o Skin Silk 4-0
o Dry sterile dressing
GASTROJEJUNOSTOMY
o Dry dressing
o Skin by simple interrupted suture using silk
4-0
o Fascia by continuous suture using vicryl 0
o Abdominal wall closure
o Complete hemostasis and sponge count
o A 4-0 seromuscular Lembert suture (2nd
layer) placed
o posterior mucosal layer approximated
using 3-0 Vicryl, as a continuous locked suture,
penetrating both mucosal and seromuscular
coats towards the anterior margin by
continuous Connell-type suturing
o A 5cm incision placed on the
antimesenteric border of jejunum and along
greater
curvature of stomach
o Lembert suture of 3-0 silk placed on
seromuscular coats of stomach and jejunum
for
about 5 cm
o longitudinal scratch mark made on the
antimesenteric border of jejunum, beginning
at a
point 12cm from ligament of Treitz, about 5cm
in length
o Ligament of Treitz identified and jejunum
brought in an antecolonic fashion
o Midline incision carried down to
peritoneum
o Sterile drapes placed

o Asepsis-antisepsis
o Patient supine
BELOW THE KNEE AMPUTATION
o Immobilization using plaster splint
o Suture line covered with sterile dressing
o Dog ears carefully tailored.
o Skin approximated carefully
o Superficial fascia sutured with interrupted
absorbable sutures
o Simple myodesis approximating the calf
muscles over the bone ends
o Hemostasis
o Muscles assessed for viability
o Wound irrigated with betadine wash
o Anterior aspect of tibia rounded and
beveled to avoid bony prominence in the
stump
o Posterior flap made
o Tibia divided perpendicularly to its long axis
with a hand or power bone saw
o Fibula divided 1cm proximal to the
intended line of division of the tibia to forma a
conical shape to the stump
o Neurovascular bundle doubly clamped,
divided, and ligated, with excessive traction
avoided
o Muscle bellies divided sharply/
electrocautery
o Skin, subcutaneous tissue, and superficial
fascia incised sharply in chosen configuration
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine
ARTERIO-VENOUS FISTULA
o Wound closed with subcuticular sutures
o Thrill palpated
o Upon completion of anastomosis, knot at
midpoint anteriorly
o Back wall sutured first from within the
vessels
o Continuous 7-0 suture used to crate a sideto-side anastomosis
o Arteriotomy then made similarly
o Incision then extended 7-9 mm with
tenotomy scissors

o Vein incised longitudinally with a pointed

blade
o Each vessel branch or tributary ligated at
least a millimeter away from the main vessel
o Radial artery and cephalic vein mobilized
sufficiently to bring them together without
angulation or tension
o Sterile drapes placed
o Asepsis-antisepsis
o Patient supine under local anaesthesia
Exploratory Laparotomy
Patient supine
Induction of spinal anesthesia
Asepsis/antisepsis
Drapings done
Vertical midline infraumbilical incision
Peritoneum open with reference clamps
Intraop findings: (size, type, location, etc.)
*omental biopsy taken
NSS lavage
Abdominal incision closed in 2 layers
Fascia closed using vicryl
Skin closed with metal staples*
Betadine paint applied
Dressing done
End of procedure
Primary repair of Abdominal Incisional Hernia
Patient supine
Asepsis-antisepsis
Sterile drapes placed
Infraumbilical incision carried down to
subcutaneous tissue
The hernial sac identified and dissected
towards the fascial defect
Entire circumference of the defect exposed
Hernial sac then opened, adhesions
released intraperitoneally
Reduction of hernial sac contents into the
abdominal cavity
Hernial sac removed
Primary closure of the fascia using Vicryl 0
continuous interlocking with interrupted silk 0
Hemostasis
Correct count
Drain if needed

 Wound closure
Subcutaneous tissue - chromic 2-0 simple
interrupted
Skin - silk 3-0 simple interrupted
Dry sterile dressing
CHIELOPLASTY
Patient supine under general anesthesia
Asepsis and antisepsis
Sterile Drapings placed
Local anesthesia given
Lip landmarks are marked out with
methylene blue
Skin incisions are made with a 6300 Beaver
blade.
The incisions are scored first, and the cleft
edge mucosal flaps are elevated.
Rotation incision is made and carried
across the base of the columella
A small, triangular-shaped piece of tissue
remains attached to the columella (Millard's
"C" flap) one sutured to the medial portion of
the nasal sill.
Along with the circumalar incision, an
incision in the intercartilaginous area of the
nasal
vestibule down to the piriform aperture frees
the nasal ala to advance medially
independently of the lip.
Incision for the interdigitation of this flap
medially just above the vermilion cutaneous
junction is not made until satisfactory
approximateion of the major flaps.
The lateral and medial lip segments are
freed by sharp dissection from the underlying
maxilla in a supraperiosteal plane.
Cleft edge mucosal flaps was excised when
the alveolar ridge is intact and rotated
upward and used to help with closure of the
alveolar cleft and anterior floor of the nose.
The lateral mucosal flap was also rotated
into the intercartilaginous incision in the nose
to avoid a raw surface at this point.
The mucosal surface sutured using a 4-0
Vicryl that grasps the lip muscle back along
the

upper edge of the advancement flap as well as

along the depths of the back cut of the
rotation incision
The orbicularis muscles are then
approximated with 4-0 Vicryl sutures.
The skin was sutured with ethilon 6-0,
beginning at the vermilion cutaneous junction
and advancing toward the mucosa
Dressing done
End of Procedure
Uranoplasty
Patient supine under general inhalation
anesthesia
Asepsis and antisepsis
Sterile drapings placed
Dingman retractor placed, the cleft
margins, adjacent hard palate, and retromolar
areas
are exposed and infiltrated with 1% lidocaine
and epinephrine 1:100.000.
Incision made at cleft margins to expose 3
layered tissue, nasal muscular palate
Mucoperiosteal flaps are then elevated
from the hard palate using a Freer elevator
The neurovascular bundle coming from the
greater palatine foramen is identified and
preserved.
The vomer flap is kept continuous
posteriorly with the nasal mucosa layer of the
soft
palate.
Muscle fibers are dissected from the soft
palate nasal mucosa for 1 to 1.5 cm. The
medial edges of the soft palate are sutured
using vicryl 4-0
Mucoperiosteum is tightly bound down to
the maxillary palatine suture and must be
freed up from the suture to provide sufficient
medial mobility of the flaps in most clefts.
The palate is closed in three layers.
This closure is performed with a simple
suture with the knots placed on the nasal side.
The mucoperiosteal flaps are sutured
anteriorly
Hemostasis

 Betadine paint applied

Dressing done
End of procedure
Z - Plasty
Patient supine under IV sedation
Asepsis and antisepsis
Sterile Drapings placed
Local anesthesia given
Lip landmarks are marked out with
methylene blue
Skin incisions are made with a 6300 Beaver
blade.
The incisions are scored first, and the cleft
edge mucosal flaps are elevated.
Rotation incision is made and carried
across the base of the columella
Single inferiorly based triangular flap on
the lateral side of the flap, which is inserted
into an incision on the medial side of the
lower portion of the lip (Z-plasty yechnique)

Along with the circumalar incision, an

incision in the intercartilaginous area of the
nasal
vestibule down to the piriform aperture frees
the nasal ala to advance medially
independently of the lip.
The lateral and medial lip segments are
freed by sharp dissection from the underlying
maxilla in a supraperiosteal plane.
Cleft edge mucosal flaps rotated upward
The mucosal surface sutured using a 4-0
Vicryl that grasps the lip muscle back along
the
upper edge of the advancement flap as well as
along the depths of the back cut of the
rotation incision
The skin was sutured with ethilon 6-0,
beginning at the vermilion cutaneous junction
and advancing toward the mucosa
Dressing done
End of Procedure