Suture Materials: Operative Notes in Brief..

OPERATIVE NOTES IN BRIEF... A.H.
than you dream more w w w . me d a d t e a m. o r g

Page 1

ABSORBABLE
rapidly:
- chromic catgut: chromic
- plain catgut (intestines of sheep )
- plain catgut is used when sutures are applied in contact with urine

- chromic catgut 4 zero :
curriculum
slowly:
absorbable Synthetic
e.g. Vicryl
NON ABSORBABLE
+ silk:
not strictly non absorbable
+ prolene
polypropylene
hernia repair
Closure of abdominal incisions in adults
Repair tendons, nerves , arteries , veins or trachea
Suture Materials
Rules
suture size :
: absorbable non- absorbable
except prolene though non-absorbable can be used inside body
:
Scalp
Face
Neck
Scrotum
drain ! drain !
- - drainage !
blood / pus /urine / bile
4 5
Page 2
Introduction:
Can be done either
- Open (inguinal or properitoneal)
or
- Laparoscopic (transperitoneal or properitoneal)
Pre-operative preparation:
Routine lab + eliminate any predisposing factor :
- chest
- prostate (male)
- reduction of weight ((for
incisional and paraumbilical
hernias especially in females))
Position : supine / dorsal
Anesthesia : General / Spinal / Local
Incision :
- Inguinal incision ( 1/2 an inch above and parallel to medial 2/3 of
inguinal ligament )
-Opening through skin superficial fascia
You may need to ligate 3 vessels:
+ Superficial epigastric
+ Superficial circumflex iliac
+ Superficial external pudendal
:
- Introduction
- Indications
- Contraindications
- Preoperative preparation
- Position
- Anesthesia
- Incision
- Technique
- Closure ( + inserting a drain or not )
- Post operative complications
Oblique Inguinal Hernia
Page 3
external oblique same direction of fibers .
: inguinal nerve - ilio Protect
- sensory loss of upper medial aspect of thigh
- McBurney : inguinal hernia + sensory loss
- .. diathermy hyperesthesia
very irritating for the patient
canal hook the cord piece of gauze
coverings cord :
external spermatic , cremastric , internal spermatic
sac : pearly white
sac cord structures neck
neck
narrowest part of the sac
extra peritoneal fat
inferior epigastric vessels
sac empty
exclude concomitant hernia
transfixion proper neck
sac : distal to ligation 1/2 inch
repair
hernia
<< :
herniotomy
same setting
general anesthesia
lower abdominal crease incision
external oblique external and internal rings
same setting
- tension repair recurrence
same setting in ilateral b
- mesh
herniorrhaphy ) (
Large defect -
Weak muscle -
Adult
!! herniotomy
Page 4
hernioplasty
very hernioraphy
+ recurrence
hernioplasty repair weak tissue risk recurrence
herniorrhaphies
( please refer to the drawings in Dr. Hassibs operative book)
[1] Plication of fascia transversalis (Lytles repair)
C
Prolene Interrupted sutures
ring tip of little finger
ring lateral
[2] Bassini repair
conjoined inguinal ligament

Prolene -
Interrupted-
- repair admit tip of your little finger
- vessel external iliac ....... ......
same direction !
Bassini under tension incision anterior rectus sheath
!
er's n Tan
[3] Blood good
anterior rectus sheath inguinal ligament
cord
Bassini Blood good Plication fascia transversalis
[4] McVay repair
fascia transversalis more posterior and inferior
pectineal ligament
femoral ring ......
femoral hernia inguinal hernia
femoral ring
Page 5
[4] Shouldice

=
Double breasting of Fascia Transversalis
+
As Bassini (suturing conjoined tendon to inguinal ligament below)
hernioraphy !
McVay / Shouldice-
repair !
Hernioplasty-
[5] Halsted
external ring cord cord subcutaneous liable for trauma

[6]Koontz

-
cord internal ring
Done specially in elderly

- mesh

o rolene P
white, 300 LE
o Merselene
o Marlex
o ortex G
- defect
spermatic cord
defect
HERNIOPLASTY
:
Page 6

Onlay : repair
Inlay : edge hernia
hernia
tendon ed conjoin
fascia transversalis
double layer mesh
:
Mair skin graft
stretching
sebaceous glands , sweat glands ,hair follicles
mesh
fascia lata patch graft
fascia lata thigh
Darning with fascia lata
strip fascia lata

Inguinal conjoined inguinal conjoined..etc
posterior wall of inguinal canal ) (
=darning
peritoneal approach pro
incision abdominal wall
peritoneum
F.T the defect
: Stoppa operation
blind incision sub umbilical
Or
Pfannensteil
peritoneum pelvis inguinal canal
mesh pelvis
Posterior to both inguinal canals

cord
bilateral inguinal hernia high risk recurrence
!
Page 7

- REPAIR
sac
Just invagination
sac neck
transfixation absorbable continuous sutures
Spermatic cord ` behind sac is medial to vessels +
shaped incision - U sliding organ
defect sac
neck purse string sutures
option :
high transfixation= transfix the sac above and away from the organ and invaginate it to
peritoneal cavity ! (High recurrence rate)
sliding hernia !
1- PARTIALLY reducible
2- Longstanding HUGE hernia
3- In case of BLADDER as a sliding organ double micturition and desire on
reduction
Direct hernia
sliiding hernia
Page 8
Pre-operative preparation: Routine lab + eliminate any predisposing factor
Position : Supine
Anesthesia : general / spinal
LOW APPROACH @
incision inguinal ligament fundus
sac neck
At inguinal ligament and pectineal
sac explore
transfix at proper neck
repair ) P to P (
Pouparts to Pectineal
approach defect
!
HIGH APPROACH @
incision oblique inguinal
i.e. Inguinal incision
) 1/2 an inch above and parallel to medial 2/3 of inguinal ligament (
superficial fascia fatty layer
membranous layer ) scarp's fascia (
external oblique
canal
cord
fascia transversalis sac
transfixion
repair ) P C P (
Pectineal Poupart
Conjoined tendon
!
repair (C to P)
Conjoined Pectineal

McVay !
!
Femoral hernia
Page 9
high approach = low approach
1 - hernia proper neck
2 - strangulation
3 - associated inguinal hernia
4 - abnormal obturator artery
abnormal obturator
3 % : pubic branch inferior epigastric artery
replace obturator artery
1 / 10 abnormal obturator artery
lacunar ligament
COMBINED APPROACH @
vertical
OR
inverted L incision
-
strangulation ) fundus (
toxic fluid sac content
Page 10
Introduction :- can be done either open or laparoscopic
Preoperative: - routine invest. & elimination of any predisposing factor e.g. obesity
Anesthesia :- general
Position :- supine
Incision :-
Ellipse enclosing umbilicus (as its a source of infection)

umbilicus transverse or semilunar
Skin superficial fascia neck
neck fundus
) (
!
To avoid adhesions at fundus
! fundus paraumbilical
In strangulation
sac content neck
defect
medial edge of recti defect Mayo
!! hernia Mayo recurrence

recti supported defect angle
series of vertical matress sutures upper flap lower flap
lower flap upper flap free edge
drain subcutaneous

natomical repair a
defect sac prolene
Hernioplasty
defect mesh
Para-umbilical hernia
Page 11
Introduction : can be done either open or laparoscopic
Anesthesia : general
Position : supine
Pre operative : routine preoperative investigations + elimination of any
predisposing factor : e.g. obesity
Techniques:
-[- Keel Repair
skin incision
sac
keel
sac invagination of sac
series of inverting non absorbable sutures ( prolene)
keel
cut section repair keel of ship
) (
Cattells Repair - [ -
6 layers repair 6 layers
1) Peritoneum
2) Fascia transversalis
3) Posterior rectus sheath
4) Rectus muscle
5) Anterior rectus sheath
6) Subcutaneous and skin
It is an anatomical repair

!!
Hernioplasty - [ -

incisional hernia repair
Incisional hernia
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O Aspiration

Done specially for ELDERLY
O Operative
anesthesia : general / spinal
position : supine
incision : scrotal ( 99% of cases ) , inguinal
1 ) Eversion Of Tunica
inguinal incision hydrocele
associated inguinal hernia
scrotal incision
Oblique or transverse
blood vessels
!
layers :
- skin
- dartos
- external spermatic fascia
- cremastric
- internal spermatic
carefully sac
sac
sac
sac
eversion of sac epididymis absorbable sutures
drain
scrotal sac
sac A.H
- subtotal excision of the tunica
Vaginal hydrocele
Page 13
Excision Of Tunica: Subtotal 2)
sac , sac
SHORT of epididymis
tunica more secretion
free edge
continuous interlocking stitches
interlocking sutures :
- more haemostatic bleeding
- purse string effect on epididymis
drain

Operation: 3) Lord's
=
plication of tunica vaginalis
with 10-12 radial stitches
- layers ......
!
Delivery of testis
Tunica

Plication of tunica vaginalis 10 - 12 stitches radial
testis

Page 14
introduction : open or laparoscopic
indication : severe pain , failure medical commission, affection spermatogenesis,
associated condition
pre operative : Doppler, semen analysis , routine lab
position : supine
incision : approach
* Inguinal:
skin
Superficial fascia
External oblique
Then deliver the cord
veins artery & vas
Cremasteric vein
!!

one or two veins from the pampiniform plexus
* Scrotal approach ( transfixation excision ) :
scrotum ) scrotal incision (
mass veins
2/3 anterior
30% testicular atrophy
recurrence
clamp clamp 5cm

transfix

Primary varicocele
o. |s _r.,
_ <u, testis
_ !!u _,rs _o , pain
_ n,,, vein
Page 15
eversion of tunica
risk hydrocele varicocele
* Delta operation :
mass vein - vein
- delta
veins

) obsolete (
* Paloma operation = Pelvic approach
) incision 3cm above external ring
Muscle fibers separation in a grid iron manner
left grid iron McBurney (
skin incision then external oblique split internal oblique and transverses abdominis
peritoneum , peritoneum
testicular vein Inside the abdomen
) (
Page 16
Indications: religious , phimosis , paraphimosis
Contraindications: bleeding tendency, Hypospadias , epispadias ) (
Preoperative: bleeding time , coagulation time
in adult : sedatives to prevent erection post circumcision ( painful)
Anesthesia: !
) ( 40 / 6 *
general / spinal / local infiltration *
crushing :

Knee flexed
and hips
tract prepuce
smegma ether ) (
prepuce
artery 6 12
mark corona
bone cutting forceps
Partially closed
glans mark
prepuce
hemostasis
outer layer
4 zero catgut
dissection :
smegma
3 9
incision dorsal skin
outer skin corona
: inner layer
Few mm from corona
hemostasis
inner and outer layers
chromic catgut 4 zero
Circumcision
Techniques of circumcision
Crushing OR Dissection

Dissection for adults neonates Crushing for
Page 17
gImportant notes:
+ fat act as pile driver =
) ( ms fibers
recurrence
+ incarcerated hernia = fecal mass irreducible
+ inguinal hernia
a. operation once diagnosed
b. if strangulation occurred
taxis herniotomy (48 hrs)
+ recurrence of hernia ,
tissues
+ Huge hernia

artificial pneumoperitoneum
peritoneal cavity
+ Bassini :1887
varicocele inspection
testis
+ incision in hydrocele:

inguinal scrotal
Page 18
introduction :
- can be done either open OR laparoscopic
- either urgent OR interval
- either routine method OR retrograde
Indications:
- Acute appendicitis.
- Recurrent subacute appendicitis
- Carcinoid tumor < 2 cm
- Portal pyemia
- Generalized peritonitis
Contraindications: mass, abscess
Pre operative: routine pre-operative investigations.
Position : supine
Incision : Mc Burney (5 cm incision centered on Mc Burney point)
skin superficial fascia
external oblique same direction of fibers
: internal oblique and transversus abdominis
splitting
peritoneum
incision RID IRON G
external oblique transvesus abdominis and internal oblique

( VERY STRONG INCISION )
skin :
More transverse
LANZ INCISION
(MORE COSMETIC AS IT IS WITH ABDOMINAL CREASE)
incision , muscle cutting incision
(not muscle splitting)

ROTTERFORD AND MORRISON INCISION
Appendicectomy
Mc Burney point : which is the point between
medial 2/3 and lateral 1/3 of a line between ASIS
and umbilicus
Page 19
doubtful diagnosis :
LOWER RT PARAMEDIAN INCISION
extension
Incision : exploratory
:
laparoscope
) IT IS EXPLORATORY (
cecum
appendix
tenia coli
follow it ( as appendix is completely surrounded by muscle layer )
mesoappendix
flush with the wall of appendix
stump
purse string sutures base
tenia coli ) (
purse string ... appendix
purse string
edematous cecum
crushing of base of appendix
crush crush kocher
base
appendix kocher's forceps
sterilization stump
invagination of stump
purse string
cecum
hemostasis

4 incisions
Page 20
appendicectomy retrograde
- appendix retrocecal adherent
- base
mesoappendix
mesoappendix
piece meal
!
g Additional notes:
ALWAYS RE-EXAMINE UNDER ANESTHESIA:
* Mass - !!
mass
rigidity of abd. wall
abd. wall lax
* mass drain .
*****
appendix normal
!!
explore :
Rt tube and ovary in females
ileum for Meckel
*****
Laparoscopic Appendicectomy
+
Less painful & hospital stay
exploratory
accepted
3 4 laparoscope
Page 21
abdominal incision
4
O ) ( accessibility
ExtensibilityO = exploratory
Safety O
Cosmetic O
specific
. McBurney e.g
* Accessible
* Extensible
* Safe
But may injure the ilioinguinal nerve
* Cosmetic
* Specific : grid iron ,

e.g. Rt paramedian for appendix
* Accessible
Mc Burney
* Extensible
* Exploratory
* Safe
* Cosmetic
e.g. subcostal :
* Cosmetic
* Accessible : Lt for spleen and Rt for gall bladder
* Safe
intercostal nerves
e.g. lumbar incision for kidney:
* Safe
subcostal nerves
* Cosmetic
e.g. paramedian for G.B. and Spleen
* Cosmetic
* accessible
subcostal
e.g. midline :
* specific :
Abdominal incisions
Page 22
Midline Incision :
- skin linea alba
Paramedian Incision :
- skin superficial fascia
1 inch from middle line
- anterior sheath
- rectus lateral
- posterior sheath
Paramedian Transrectal Incision :
obsolete
rectus muscle
Pfannenstiel incision :
( transverse suprapubic )
skin superficial fascia
anterior sheath
separate 2 recti laterally !!
in lower of recti Posterior rectus sheath
Oblique Subcostal :
- : kocher
- : left subcostal
costal margin 1 inch
skin , superficial fascia
anterior rectus sheath
rectus muscle : transversely
transverse
segmental
arterial and nerve supply
posterior sheath
laterally 3 muscles : EO , IO , TA
: lateral
-to preserve blood and nerve supply from lateral side
- OBST&GYN peritoneum
- urinary bladder peritoneum
!!
Page 23
Introduction: can be done wither open or laparoscopic
Laparoscopic:
either
- morcellation (completely through laparoscope)
OR
- laparoscopically assisted
) laparoscope
incision spleen (
Indications:
Traumatic injury spleen
Hematological disorders
Lymphoma
Portal hypertension ( : if huge with hypersplenism, ..etc)
During radical surgery stomach
) stomach drainage to Splenic LNS (
Wandering spleen
(spleen with a long mesentery , more in childen, liable for torsion)
!!
Contraindications:
Children OPSI
Sickle cell anemia (autosplenectomy)
Extensive adhesions (as in portal HTN)
OPSI= overwhelming post-splenectomy infection
Pre-operative:
Routine lab
hemolytic anemia
gall bladder
With US for stones
Position: supine
Anaesthesia: general
Incision: Upper LT pramedian OR LT Subcostal
abdominal incisions
(See before)
downwards and medially
Clamp
posterior leaflet lieno-renal ligament
lower pole

Splenectomy
Page 24
upper pole
short gastric vessels
artery doubly ligated

Squeeze autotransfusion ) (
vein
peritoneal attachments

field dry .. !!
trauma !! Explore abdomen
anemia hemolytic splenules
hilum
pancreas of tail
gastrosplenic ligament
broad lgament
---------------------------------------------------------------------------------
splenules !
Accessory Splenic tissues, as spleen is formed in the posterior
mesogastrium, from multiple splenules
spleen splenules
splenosis !
Abnormally implanted Splenic tissue in peritoneal cavity after
Splenic injury
----- --------------------------------------------------------------------------
hemolytic anemia
explore the gall bladder
: !! same setting
Incision: middle line or double Subcostal
!!
hemolytic crisis stones

Trauma
Hemolytic anemia
Portal HTN
- portal HTN
extensive adhesion
irresectable
Splenic artery
Page 25
Introduction: can be done either open or laparoscopic
Indications: start with inflammatory, then traumatic, congenital and Neoplastic
Contraindications: asymptomatic gall stones, liver cirrhosis
Pre-operative: routine lab investigations
Position: supine
costal margin
Anaesthesia: general
Incision:
(KOCHER) Rt Subcostal wide Subcostal angle standard
OR
patient with a narrow in a tall an upper Rt paramedi
Subcostal angle
abdomen
clamp fundus Hartman pouch
peritoneum free border lesser omentum
Y junction Calot triangle
artery
duct !! operative cholangiogram
duct 5 mm CBD

retrograde cholangiography !

fundus 1
st
cholecystectomy

apply ligature during traction
CBD and RT hepatic artery
drain
field dry
Complications:
+ CBD injury
+ Hemorrhage
How to manage?
pack
control under vision
(dont apply blind ligature !! )
injury during the operation?? Causes of CBD
1) Application of ligature during traction
2) Application of blind clamps to control bleeding
3) If surgeon is not oriented with congenital anomalies in this area
Cholecystectomy
Cholecystectomy
!! Dont apply ligature during traction
Page 26
AT THREE LEVELS:
A] SUPRA-DUODENAL

B] RETRO-DUODENAL CHOLEDOCHOLITHOTOMY
peritoneum RT side of the duodenum
mobilize duodenum
n of duodenal part of CBD = kocherizatio - Mobilization of the duodenum to see retro (
) the duodenum
C] INFRA-DUODENAL PART:
through 2
nd
part duodenum
duodenal papillae
CBD exploration
Page 27
Written BUT for COLOSTOMY study indications and titles!!
Indications of colostomy:
permanent OR Either temporary

- Simple loop colostomy
simple loop loop abdominal wall
mobile part of colon
(transverse and sigmoid)
colostomy
colon Hartman
- Devines defunctioning colostomy
colostomy
mucous fistula

evine defunctioning D !
distal colon defunctioned stool
- Caecotomy
gases
stools
Principles of colon surgery
Permanent
Irresectable carcinoma
after abdomino-perineal
resection
Temporary
As (Neoplastic) operable carcinoma
(congenital) imperforate anus
traumatic
inflammatory stricture
Page 28
Indications:
3
rd
and 4
th
degrees
1
st
and 2
nd

Preoperative: routine lab
Anesthesia: general or spinal
Position: LITHOTOMY position
- PR carcinoma rectal !!
dilatation 4 fingers
post-operative pain
bladder forceps muco-cutaneous junction
artery forceps pedicle
bladder forceps Palm of one hand
index finger pedicle as a guide

skin incision V-shaped pile
subcutaneous
submucosal
pedicle
Crush
transfixation
With absorbable sutures
distal to ligature 1/2 an inch
3 3 7 11
3 raw areas
!!
!
intact mucosa and skin between the 3 raw areas
stricture
flavine gauze
!
Haemorrhoidectomy
Page 29
Indications:
TEMPORARY:
oesophagus
As (congenital) atresia
(traumatic) perforation
(Neoplastic) operable carcinoma
PERMANENT
irresectable unoperable oesophageal tumour
!
Technique: (( Stams gastrostomy )) :
Upper left paramedian
stomach
greater and lesser curvature
3 purse string sutures
gastrostomy tube
3 purse string sutures
tube stomach peritneum
Gastrostomy
Page 30
Introduction: can be done wither open or laparoscopic
Indications:
`
LARGE 1RYO
COMPLICATED 2RYO
Contra-indications
Deep system occluded
Pre-operative:
o Routine lab
o Doppler/duplex
o angiography
Anesthesia: General or spinal
Position: supine
TRENDLENBERG OPERATION O
Incision:
incision inguinal ligament
vein long spahenous
flush deep system
tributaries
Which are: superficial circumflex iliac, superficial epigastric, superficial external pudendal,
deep external pudendal, accessory saphenous vein are identified, ligated and divided
5
Trendlenbergs operation:
isolated sapheno-femoral incompetence
saphenous is markedly affected with multiple incompetent perforators

+
O SUBCUTANEOUS STRIPPING OF LONG SAPHENOUS
trendlenberg
upper end
lower end of saphenous
saphenous nerve
) venous cutdown - (
upper end
stripper
Surgical ttt varicose veins
Page 31

With direction of valves
long saphenous stripper
stripper
vein
clip bandage
O SUBFASCIAL LIGATION
<< ankle perforators
2 4 6 inches above medial malleolus
Incision:
incision tibia with 1 inch
Technique:

o Skin
o Superficial fascia
o Deep fascia
flush deep system
subfascial ligation
recurrence
blow-outs

endoscopic
Page 32
Indications:
Contraindications:

Less than 25 years old (due to high rate of recurrence)

recent progressive exophthalmos
high thyroid antibody titre
Preoperative:
o Routine lab
o Indirect laryngoscopy (of medico-legal importance)
Anaesthesia: General
Position:Supine and neck is extended
head table
Incision:
Kocher incision (1 inch above supra-sternal notch)
Technique:
skin
platysma
upper flap hyoid bone
lower flap better exposure pocket
between pre-tracheal muscles
- sternohyoid
- sternothyroid
- thyrohyoid
strap muscles
Split the pretracheal muscles
muscle cutting !
If huge, malignant or toxic

nerve supply
Ansa cervicalis
Thyroidectomy
Page 33
vessel Middle thyroid vein
internal jugular vein
lobe
superior thyroid artery and vein lobe within lobe ) (
anterior branch posterior branch
inferior thyroid veins fragile
inferior thyroid artery
away from gland
acute ischemia (parathyroid)
postero-medial part

!
= surgeons experience

8 gm
distal phalynx
simple nodular
toxic?
3 / 1

oesophageal and tracheal branches
drain
isthmus thyrtoidectomy
isthmus recurrence very early
parathyroid
muscles forearm
re-implantation
Page 34
indications :
upper air way obstruction
ventilator
SEMI-EMERGENCY
anaesthesia: General or local
position : supine with neck extended
Incision: transverse or vertical incision skin of platysma
Technique:
split the pretracheal muscles
Isthmus
trachea
2nd,3rd,4th tracheal rings
tube

2nd , 3rd , 4th
larynx

innominate vein
Tracheostomy
(Q ) Emergeny?

alternative emergency
upper airway obstruction?
Endotracheal tube or
cricothyrodotomy
Page 35
Indications: in stage 1 & 2 breast carcinoma
Pre-operative preparation: Routine lab. & metastatic work up
Anesthesia : general
Position : Supine, arm abducted
arm abducted
axilla
Briedels scar
s scar ? l e ried B
Its a scar that prevent abduction
Technique:
skin ellipse nipple & areola
[5 cm from mass & site of biopsy]
ellipse latissmus laterally & middle line medially
) see last two diagrams p.64 (
Oblique
upper flap CLAVICLE
lower flap UPPER 1/4 RECTUS SHEATH
anatomical land marks of breast

1/4 rectus & clavicle , ally middle line medi latissmus laterally ,
Radical mastectomy
Page 36
fascia anatomical land mark
axilla radical Halsted
insertion of pectoralis minor sterno costal head of pectoralis major
axilla patey minor
axilla fat and lymph nodes (Medial to the axillary vein not lateral)
Halsted ribs Inter costal muscles
Patey pectoralis major fascia
hemostasis
2 suction drains Seroma formation complication

structures complications
1- axillary vessels and nerves
] axillary nerve Axillary nerve circumflex
brachial plexus circumflex [
2- nerve to latissimus dorsi
3- nerve to serratus anterior
4- cephalic vein

indications of simple mastectomy ?
1- inoperable case
2- fungating mass
3- cystosarcoma phylloides
4- T.B
5- sarcoma
simple mastectomy
radical
Pattey
lymph nodes
Page 37
LUMBAR TRANSABDOMINAL
+ lumbar
1 inch below renal angle
A point 1.5 inches above the ASIS
) Abernathy (
skin 3 muscles 3 muscles fascia
- external oblique , internal , transversus
- : latissimus dorsi, serratus posterior inferior, quadratus lumborum
- lumbar fascia
peritoneum zucker kandel fascia
perinephric fat
upper pole lower pole assistant
. sound .
bridge table
last rib
transabdominal exposure :
- It has 2 indications: (= rupture kidney)
1. malignancy
2. trauma
Exposure of Kiidney
Page 38
dney stone ki pelvis
clear) ( fat pelvis incision in pelvis long
axis

distal patency
Flush with saline
pelvis 3
1 . plain cat gut
2 .
3 .
infected urine ----
not infected ------
) (
distal patency distal obstruction or specific pathology
urinary fistula
) complication urology (
if the stone is impacted in renal parenchyma

Nephrolithotomy ) plz check P.77 (

1 - Radial
2 - Brodel"s line
Brodels line
1 / 2 convexity Kidney cm posterior
kidney
Branching stone PYELONEPHROLITHOTOMY
pelvis kidney
recurrent lower calyx localized hydronephrosis PARTIAL
NEPHRECTOMY kidney functioning other kideny
NEPHRECTOMY
Removal of renal calculi
Page 39
upper 1/3 lumbar incision kidney ) pyelolithotomy (
, middle 1/3 Abernathy
lower 1/3
Ischeal spine Abernathy
Ischeal spine suprabupic
Nephroureterectomy 2 incision only
(plz check diagram P.79)
Position : Supine
Incision: 1 & 1/2 Inches above & Infront The ASIS to one inch above mid
inguinal point
3 muscles ascia & skin & Superfascial f
( External oblique , Internal oblique & transversus Abdominus )
3 muscles & Fascia transversalis
peritoneum
peritoneum medially
ureter
1- It crosses the bifurcation of common iliac artery
2- peristalsis
3- blood vessels
4-
5- Longitudinal structure
6- On aspiration urine
ureter peritneum
ureter
Milk impacted
Surgical ttt Of Stone Ureter

INDICATION OF NEPHROURETERECTOMY
1-T.B (Kideny)
2-Transitional cell carcinoma of renal pelvis
3-Pyonephrosis
4-Pyoureter
ABERNATHEYs Operation
Page 40
risk stricture ) unhealthy area (
Milk healthy ureter
) flush with saline (
distal patency
ureter 3 ) (

plain catgut
infected urine infected
drain
urology drain nephrectomy
kidney posterior drain nephropexy
posterior abdominal wall
introduction: in spite of being very simple procedure it may be a life saving
one.
Anesthesia: local
Indications: shocked patient
CEPHALIC .
cephalic long saphenous long saphenous
arterial construction cephalic long saphenous
Incision: 1 inch above radial styloid process in case of cephalic vein. OR
1 inch above and in front of medial malleolus in case of long saphenous
vein
Long saphenous saphenous nerve
vein proximal and distal (check 2
nd
diagram page 88)
distal
vein [plz check 3
rd
diagram page 88 ](1mm or 2 mm)
cannula proximal cannula
Cannula (Plz check 3
rd
diagram and 4
th
diagram page 88)
wedge resection .
Venous cut down
Ingrowing toe nail
Page 41
Indications for rib resection
rib tumour or osteomyelitis or TB
graft
rib

exposure kidney, subphrenic abscess, amoebic liver abscess,heart,pleura, lung,
oesophagus, big vessels
Anaesthesia: general or intercostals nerve block
Technique:
Skin incisin: rib
skin
periosteum
periosteum periosteal elevator
(2
nd
diagram, page 87)
posterior periosteum Doyan raspatory
(pls check 1
st
diagram page 87)

Intercostal vessels
Strip the posterior Periosteum
rib rib shear
] rib ) check 2
nd
diagram page 87 ( [
rib resection 3
Periosteal elevator , Doyan respatory , rib shear
Rib resection
rib cervical rib periosteum
tumor periosteum rib rib .
TB periosteum affected
streptomycin carbolic acid periosteum empyema TB
Page 42
introduction: decision of amputation should never taken lightly and a second
opinion of a senior must be obtained
Anesthesia: general or spinal
Position : supine
Indications:
limb : ) dead limb ( : vascular causes
Lethal limb : e.g. sarcoma, gas gangrene, Crush syndrome
Limb : flail limb sciatic nerve injury can't be repaired &
: amputation
Incision: 1 inch above
Technique :
Tourniquet vascular trauma
Plz check 1
st
diagram in technique page 92 ) (
skin
Equal flaps
but in below knee amputation: Long posterior flap
(Plz check 2
nd
diagram )
muscles
skin bone section (Plz check last diagram page 92)
nerve bone section
artery
bone
- HAND BREADTH TIBIAL TUBEROSITY below knee
amputation hand breadth patella above knee amputation
- below knee fibula1 inch above the level of tibia
- periosteum spur formation
(Plz check 1
st
diagram page 93)
- bone hemostasis muscles bone
(Plz check 3
rd
diagram page 93)
muscles bone drain bandage
mould ) stump amputation ( artificial limb
) Plz check last diagram page 93 (
Amputation
1 - limb
2 - limb
3 - limb
Page 43
Introduction : it can be done either opened or laparoscopic
Indications :
1- vascular causes
2- hyperhydrosis
3- painful conditions :e.g. bladder carcinoma
Contraindications:
1- extensive gangrene ( ineffective + needs amputation )
2- intermittent claudications ( worsen the muscle ischemia )
3- diabetic ( auto sympathectomy )
anesthesia: general
incision:
tip of last rib umbilicus lateral border of rectus
plz check 1
st
diagram page 97
Position :
Partly on the opposite side
Lateral Kidney supine
skin 3 muscles
external oblique , internal oblique , transversus
peritoneum peritoneum groove
psoas muscle lumbar vertebrae
2
nd
lumbar ganglion 3
rd
part duodenum
common iliac artery
1
st
ganglion Failure of
ejaculation
pre ganglionic sympathetic fibers lumbar
ganglia synapse synapse
in lower lumbar ganglia and in sacral ganglia
PREGANGLIONIC SYMPATHECTOMY
sympathetic IVC
Qs : sympathetic chain
Psoas minor tendon , tendinous fibers of muscles , genitofemoral nerve , lymphatics
Q :
Sympathetic chain has ganglia
Q : sympathetic
Para vertebral block ,
Lumbar sympathectomy
Page 44
complications :
hemorrhage, injury, infection
Ileus , DVT, burst abdomen
:
appendicectomy, splenectomy, gall bladder colostomy
special complications
HEMORRHAGE piles discuss & Primary,
secondary reactionary
INJURY amputation
Injury
discuss injury gall bladder common bile duct
INFECTION , spleen OPSI amputation gas
gangrene infection above knee
he defecates) pan stools ( gas gangrene
SPECIAL COMPLICATIONS
1- Oblique inguinal hernia,
recurrence.
risk factors are as in incisional hernia post operative and Pre operative
operative :
a- Transfixion not at proper neck
b- Repair under tension
2- Hydrocele, recurrence
3- Circumcision, incomplete or excessive removal
4- Appendix: inguinal hernia, or incisional hernia
5- Splenectomy: portal vein thrombosis
: thrombosis in splenic vein extension portal vein
6- Gall bladder : post cholecyctectomy syndrome
5s
a- Stricture in common bile duct
b- Stone in common bile duct
c- Spasm in sphincter of Oddi (dyskinesia)
d- Sorry diagnosis = wrong diagnosis
e- Long Stump
7- Piles:
a) Stricture is very dangerous
b) pain and retention
General complications of surgery
Page 45
stricture
intact mucosa or skin
8- Mastectomy: lymphoedema, seroma, Briedls scar
9- Kidney: urinary fistula( because of distal obstruction & specific pathology)
10- Tracheostomy: obstruction , surgical emphysema
11- Amputation: phantom limb
,
3
1 - Balooza= unsafe limb
unsafe limb muscles
2 - Spur formation
3 - neuroma
INDEX
Suture Materials ----------------- ----------------------------------- 1
Oblique Inguinal Hernia -------------------------------------------- 2
Direct Inguinal Hernia----------------------------------------------- 3
Sliding Hernia ------------------------------------------------------- 3
Femoral Hernia ------------------------------------------------------ 8
Para-Umbilical Hernia -----------------------------------------------10
Incisional Hernia ----------------------------------------------------- 11
Vaginal Hydrocele -------------------------------------------------- 12
Primary Varicocele -------------------------------------------------- 14
Circumcision -------------------------------------------------------- 16
Important Notes ----------------------------------------------------- 17
Appendicectomy --------------------------------------------------- 18
\ _.:+ , `..+ \, ' ` ` ..
_ ':, ' `,. ': '_ AH .:,` _. ':.._ _
Page 46
Abdominal Incisions ------------------------------------------------ 21
Splenectomy -------------------------------------------------------- 23
Cholecystectomy --------------------------------------------------- 25
CBD Exploration ------------------------------------------------- 26
Principles Of Colon Surgery ----------------------------------- 27
Hemorrhoidectomy ------------------------------------------------ 28
Gastrostomy -------------------------------------------------------- 29
Varicose Veins ----------------------------------------------------- 30
Thyroidectomy ---------------------------------------------------- 32
Tracheostomy ----------------------------------------------------- 34
Radical Mastectomy ---------------------------------------------- 35
Exposure Of Kidney -------------------------------------------- 37
Removal Of Renal Calculi -------------------------------------- 38
Stone Ureter ----------------------------------------------------- 39
Abernatheys Operation ---------------------------------------- 39
Venous Cutdown ------------------------------------------------- 40
Ingrowing Toe Nail ----------------------------------------------- 40
Rib Resection ------------------------------------------------------ 41
Amputation -------------------------------------------------------- 42
Lumbar Sympathectomy ----------------------------------------- 43
General Complications Of Surgery ------------------------- 44

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than you dream more w w w . me d a d t e a m. o r g

external ring cord cord subcutaneous liable for trauma

* Specific : grid iron ,

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