CVP INSERTION

Patient positioned supine

Asepsis/Antisepsis
Drapings done
Infiltration of local anesthesia
Incision done proximal to the cubital area done, deepened
Isolation of basilica vein done
Veinotomy, cannulation with Fr. 8 feeding tube, patency checked
Distal portion of the vein ligated
Feeding tube anchored, three-way stop cock hooked and attached to mano meter
Skin closure with silk 3/0
Top dressing done
End of procedure.

I AND D SUTURING OF WOUND

Patient positioned supine
Asepsis/Antisepsis
Drapings done
Infiltration of local anesthesia
Irrigation/debridement of lacerated wound (location)
Suturing of wound with nylon 4/0
Betadine paint
Top dressing done
End of procedure.

AVF CREATION
Patient positioned supine with L arm laterally extended
Asepsis/Antisepsis
Drapings done
Infiltration of local anesthesia
Incision done over forearm, deepened
Localization of radial artery, isolated
Vein ligated at distal portion, proximal portion approximated to the artery
Arteriotomy done, then AV fistula created, using nylon 6/0 double arm
Bleeding checked, hemostasis, bruit checked and appreciated
Closure of skin with nylon 6/0 - matress
Top dressing done
End of procedure.

Fistulotomy
Induction of spinal anesthesia
Patient placed in dorsal lithotomy position
Asepsis/Antisepsis/Drapings
Anoscopy done
Erguson retractors applied
External openings probed and noted tract leading towards the anal mucosa
Feeding tube with peroxide solution inserted in the external opening to identify the internal
opening in the anal mucosa
Fistula probe inserted and tract identified, unroofed with cold and warm knife
External opening excised
Tract debrided with curette
Hemostasis
Perieal mole excised
Palmar wart in the thumb of R hand cauterized
Top dressings with Povidine Iodine and Operative sponges
End of procedure.

CTT
Patient positioned
Identification of the 5th ICS in the Axillary line
Sterile prepand drapings done
Infiltration of lidocaine anesthesia at a level below the pre-marked 5 th ICS
A horizontal skin incision done & deepened down to the subcutaneous fat with the kelly clamp
a tract is created from the incision site superiorly posteriorly & immediately above the superior
edge of the 6th ribs avoiding injury to the neurovascular bundle
Upon entering the pleural space, a gloved finger is placed through the tract into the pleural
space
Palpation to the lung to confirm pleural cavity location & assuring no adhesions are present
Proximal end of the chest tube is grasped with a Kelly clamp and both inserted through the
subcutaneous tract into the pleural cavity directing the tube posteriorly towards the apex
Tube attached to water sealed bottle & securely anchored to the skin with silk sutures
Vaselined gauze placed around the tube to seal
Top dressings done
End of procedure.

CLOSE TUBE THORACOSTOMY R

Patient positioned supine
Asepsis/Antisepsis
Drapings done
Induction of anesthesia
Incision done at R anterior auxillary line 6th ICS
Blunt dissection of the muscles up to the intercostals

Pleural puncture done

Insertion of chest tube Fr 32 guided by the index finger, positioned in place
Rubber tubing attached to the chest tube, initial straw-colored drain ~__cc, then attached to
thoracostomy bottle
Tube anchored to skin with silk0skin closure with silk 3/0
Top dressing done
End of procedure.

PD Cathetererization/ Tencknoff
Induction of anesthesia
Patient positioned supine
Asepsis/Antisepsis
Drapings done
Skin incision done R parerectus 5cm from & below the umbilicus
Incision deepened down to the peritoneum, muscles split
Purse string sutures placed using vicryl 3-0
Peritoneum penetrated & Tencknoff catheter inserted catheter left intraperitoneally
Fascia & Rectus muscles approximated using vicryl 2-0 figure of 8
Skin closed w/ silk 4-0, simple mattress
Betadine paint
Top dressings done
End of procedure.

IJ catheter insertion
Patient positioned supine
Asepsis/Antisepsis
Drapings done
Infiltration of local anesthesia
Sildinger need inserted to the needle, needle removed leaving the guidewire
needle
vein
Dilator inserted, dilating internal
jugular site and jugular vein
Jo-line inserted catheter inserted into the guidewire, guidewire removed
Patency checked, infiltration of heparin on catheter tip, locked
Catheter anchored with silk 3-0
Top dressing done
End of procedure.

Pericardiostomy Tube Insertion

Induction of anesthesia
Patient positioned supine
Asepsis/Antisepsis
Drapings done
Vertical incision done from the xiphisternal junction down to the tip the xiphoid process
Blunt dissection is done to define the retrosternal plane
Pericardium approached extraperitoneally
Pericardium opened by a scalpel
Fluid control-sunctioned
Pericadiostomy tube inserted, exteriorized separate from incision site
Tube attached to closed tube system
Closure
Tube secured with sutures
Top dressings with Povidine-Iodine and operative sponges
End of procedure.

External fixation
Patient positioned
Wadding sheet applied from foot to proximal leg
Plaster of Paris wet and applied in circular manner
Molded and allow to dry
End of procedure.

Excision with Frozen Section Biopsy

Patient positioned supine
Induction of anesthesia
Asepsis/Antisepsis
Drapings done exposing the incision area
Incision done on RUQ
Excision of (size & char) mass on R breast
Bleeders controlled, hemostasis done as controlled
Skin closure using _____
Betadine paint
Top dressing
End of procedure.

Tracheostomy Tube Insertion

Patient positioned supine
Asepsis/Antisepsis
Drapings done
Infiltration of local anesthesia
Skin incision done horizontally over the 2nd to 3rd tracheal ring
Incision deepened down to the subcutaneous fat and platysma
muscle & exposing the sternohyoid muscles
Hemostasis
Elevation of the strap muscles done, making a vertical incision in the
midline separating these two strap muscles
Incision was carried down to the upper trachea, exposing & dividing the
capsule of the thyroid gland

The isthmus as it crosses the trachea is retracted in the cephalad direction

revealing the 2nd & 3rd tracheal ring
Incision of the 2nd & 3rd tracheal ring done providing adequate
tracheostomy opening
Cuffed endotracheal tube inserted into the tracheal incision, while the
endotracheal is extracted
Silk suture placed through the incision site on each side
Tracheostomy dressing done
End of procedure.

Same procedure done at the contra-lateral thyroid lobe

Release of the entire thyroid gland done
Hemostasis done, washing
Release of skin traction and closure done
Drain applied and left in place
Skin closure with vicryl 4/0 subcuticular stitch
Top dressing done
Specimen for histopathology
End of procedure.

MRM
Induction of anesthesia
Patient positioned supine
Foley catheter insertion done
Asepsis/Antisepsis
Drapings done leaving the operative site exposed
Stewart skin incision done, extending down perpendicular to the
Subcutaneous plane with 5-8 mm thickness
Skin &subcutaneous flaps developed.
Superiorly up to the subclavius muscle
Inferiorly up to the caudal extension of the breast 2 cm inferior to the inferior to
the inframammary fold
Medially up to the midline of the sternum
Laterally up to the anterior margin of the latissimus dorsi
Bleeders clamped and ligated between sutures
Breast Tissue removed at the Pectoralis Major Fascia above the
Pectoralis Musculature using the electrocautery and scalpel
Perforator vessels clamped, ligated between silk sutures
Breast & skin elevated pectoralis fascia from the lateral humeral extension to the medial
costochondrial junction, are elevated en bloc
The lateral flap is elevated to the anterior margin of the latissimus dorsi
Loose areolar tissue of the lateral axillary space elevated with identification of the lattermost
extent of the maxillary vein
Dissection proceeds medially identifying the Long thoracic nerve & preserved; thoracodorsal
nerve likewise identified & preserved
Entire breast & fascia are cleared medially & inferiorly from the aponeurosisof the rectus
abdominis muscle
Operating field carefully inspected & bleeding points identified, clamped & ligated
Closed sunction drain left in place at the axilla & brought out to separate skin site
Skin approximated with interrupted non-absorbable sutures, &
subcutaneous w/ vicryl 4-0
Betadine paint
Top pressure dressing
End of procedure.

Modified Neck Dissection, Thyroidectomy

Induction of general anesthesia
Patient positioned with neck hyperextended
Asepsis/Antisepsis
Drapings done
Incision deepeded to the areolar tissue plane just below the platysma
Sharp dissection alternate with blunt dissection done to facilitate freeing of the
upper flap, isolation and excision of thyroid gland done
Dissection progressed with the exposure of thevsternocleidomastoid, the
dissection then shifted to the posterior cervical triangle, exposing
the borders of the trapezius muscles
Lower flap produced, application of traction
Identification of the external jugular vein done and preserved, and
spinal accessory nerve identified and divided, dissection
carried down to the superior aspect of the clavicle
Common carotid artery exposed, dissection continued inferiorly and extended superiorly,
following the floor of the neck or the prevertebra fascia
All loose areolar tissue about the caritod artery removed
Superior dissection continued exposing the hypoglossal nerve, submental dissection done.
Traction of the maxillary gland done to expose lingual nerve, salivary duct and
hypoglossal nerve.
Anterior belly of the omohyoid muscle is divided from the sling of the digastric muscle.
Dissection completed after the posterior belly of the digastric muscle is exposed
Retraction of the posterior belly of the digastric superiorly exposed the internal jugular vein,
vein clamped and divided.
Internal jugular vein clamped high, dissection completed with the division of the
sternocleidomastoid in the mastoid process.
Bleeders clamped and ligated
Hemostasis done, washing
Platysma approximated and closed
Release of skin traction and closure done
Drain applied and left in place
Skin closure via subcuticular stitch
Top dressing done
End of procedure.

TOTAL THYROIDECTOMY
Induction of general anesthesia
Patient positioned with neck hyperextended
Asepsis/Antisepsis/Drapings
Incision done dividing the skin and subcutaneous tissue
Incision deepened to the areolar tissue plane just below the platysma
Sharp dissection alternate with blunt dissection done to facilitate freeing of upper flap
Dissection reaching the thyroid notch, exposing the entire thyroid cartilage and downward to
the suprasternal notch
Lower flap produced, application of traction
Plane of cleavage between the sternocleidomastoid muscle and the outer boundaries of the
sternohyoid muscle
Plane develop with sharp and blunt dissection between the thyroid gland and sternohyoid
muscle
Bleeders clamped and ligated
Release of thyroid gland at the superior pole by blunt dissection
Vessels preserved, identification of the recurrent laryngeal nerve done and preserved
Release of thyroid gland at the middle and inferior pole done, identify the middle and inferior
thyroid vessels
Isthmus identified and released

VP Shunting
Induction of anesthesia
Asepsis/antisepsis
Drapings done leaving operative exposed
R parietal scalp incision done over the periosteum
Burr hole craniotomy done. Dura exposed and incised
Abdominal skin incision done over the R pararectus muscle 3 cm above the umbilicus
Incision deepened down to the peritoneum
Shunt passer inserted subcutaneously from the scalp incision towards the
abdominal incision
Ventriculoperitoneal shunt guided through the shunt passer and shunt passer
pulled out
Shunt device anchored to the craniotomy, scalp closed with nylon 3-0
Peritoneal end of the shunt left inside the peritoneum
Peritoneum closed with vicryl 2-0
Rectus muscles approximated with vicryl 3-0 using fig of 8
Rectus fascia closed with vicryl 3-0 using continuous running sutures
Skin closed with simple interrupted sutures using silk 3-0
Betadine paint
Top dressing
End of procedure.

Left Hemicraniectomy
Induction of anesthesia
Asepsis/antisepsis
Drapings done leaving operative site exposed
L parietal scalp incision done up to the periosteum
Bleeding controlled, hemostasis done as encountered
Holes borred through the cranium 2-3cm apart
Gigly wire guide passed through and wires passed,
Cranium cut through the giggly wire, done at entire span of Left cranium
Craniectomy done, dura exposed which is densed
Hemostasis with surgical and electrocautery
Exposed dura closed with apposition of aponeurosis
Skin closure with nylon continuous mattress suture
Top dressing done
End of procedure.

CRANIOTOMY CLIPPING ANEURYSM

Patient supine
Induction of general anesthesia
Craniotomy prep done and drapings placed, secured with sutures
L fronto-parietal incision done, deepened, traversing skin, subcutaneous tissue, dense
connective tissue, epicranial aponeurosis, temporalis muscle loose connective tissue,
periosteum
Clamps adequately placed, secured in groups with elastic bands
Periosteum seperated from calvaria
Bleeders controlled as encountered
Burr hole made on points for otomy, dura left intact separated from inner table by dissector and
wire guide, proceeded with Gigly wire cutting, calved separated from dura
Protruding portions Rougeured off
Leyla retractors applied, secured
Dissection done up to the level of the optic chiasm
Anterior circulation of the Circle of Willis identified
Anterior communicating artery identified, aneurysm located
Aneurysm clipped with permanent clips, wrapped with crayanoacrylate coat cellulose fiber
Profuse irrigation
Hemostasis
Duraplasty with vicryl 3-0
Insertion of JP drain, exteriorized separate from incision site, secured with sutures
Calvria replaced
Closure of scalp
Connective tissue, aponeurosis using vicryl 3-0 simple interrupted
Skin, subcutaneously using nylon 3-0 vertical mattress
Betadine paint

Top dressing done with OS

End of procedure

End of procedure.

Nephrectomy
Appendectomy Drop Method via Rocky Davis Incision
Induction of spinal anesthesia
Patient supine
Asepsis/Antisepsis
Drapings done
Transverse incision done at McBurney,s point (Rocky-Davis Incision)
Incision deepened, traversing the skin, subQ, transversalis fascia, muscles and peritoneum
Hemostasis
Appendix isolated
Appendiceal artery identified, clamped, cut, ligated with silk 3-0
Appendix base clamped, cut and secured with use of purse string stitch using silk 3-0
External oblique with chromic 3-0
Fascial closure
Skin closure with nylon 3-0
Wound painted with povidine iodine
Top dressing done
Specimen for histopathology
End of procedure.

Appendectomy - Ruptured
Induction of anesthesia
Foley catheter insertion done
Asepsis/antisepsis
Drapings done leaving operative site exposed
Rocky-Davis skin incision done over the R lower quadrant
Skin incision deepened down to the peritoneum
Retractors applied. Appendix identified and isolated
See above intra op findings
Appendectomy done Drop Method
Hemostasis
Drain, penrose left at the R gutter & brought out through a separate incision
Closure done layer by layer
Peritoneum closed with vicryl 1-0, continuous running sutures
Muscles approximated w/ vicryl 1-0 continuous interlocking sutures
Skin closed w/ vicryl 4-0 subcutaneously
Betadine paint
Top dressing
End of procedure.

Craniotomy, Evacuation Hematoma

Induction of anesthesia
Aspesis/Antisepsis
Drapings done leaving the operative site exposed
L parietal scalp incision done up to the periosteum
Craniotomy done, Dura mater exposed and incised
Evacuation of blood/ blood clots done
Flushing in dural space with catheter until return flow is clear
Dura repaired, scalp closed with vicryl 3-0
Skin closure with nylon continuous mattress suture
Top dressing done
End of procedure.

Craniotomy Tube Ventriculostomy

Patient supine
Induction of general anesthesia
Craniotomy prep done and drapings placed, secured with sutures
Previous incision site of (L) ventriculostomy entered
Ventriculostomy tube removed, needle inserted to assess flow of CSF
Insertion of new tube done and attached to a collecting bag
Profuse irrigation
Hemostasis
Closure of scalp using silk 3-0 full thickness via Horizontal mattress
Top dressing with povidine iodine and OS
End of procedure.

ORT VP shunting
Induction of Anesthesia
Asepsis/ Antisepsis
Drapings done leaving operative site exposed
R Parietal scalp incision done to the periosteum
Burr hole craniotomy done. Dura exposed and incised
Abdominal skin incision done over the R pararectus muscle
3 cm above the umbilicus
Incision deepened down to the peritoneum
Shunt passer inserted subcutaneously from the scalp incision
towards the abdominal incision
Ventriculoperitoneal shunt guided through the shunt passer and
shunt passer pulled out
Shunt device anchored to the craniotomy, scalp closed w/ nylon 3-0
Peritoneal end of the shunt left inside the peritoneum
Peritoneum closed with vicryl 2-0
Rectus muscles approximated w/ vicryl 3-0 using fig of 8
Rectus fascia closed w/ vicryl 3-0 using continuous running sutures
Skin closed withsimple interrupted sutures using silk 3-0
Betadine paint
Top dressing

Induction of anesthesia
Patient on L/R lateral decubitus position
Asepsis/antisepsis
Drapings done leaving operative site exposed
L/R lumbar incision, deepened
Lumbosacral fascia opened
Kidney isolated from the perinephric fat
Renal artery identified, clamped, cut, and ligated
Hemostasis
Drain placed
Closure (lumbodorsal fascia/sub cutaneous skin)
Top dressing done
End of procedure.

Pyelolithotomy
Induction of anesthesia
Patient placed in the standard flank position, table is broken, and tapes are placed to secure
the patient
Asepsis/antisepsis
Drapings done
Subcostal incision is done started at the lateral border of the sacrospinalis muscle 1 cm below
the lower edge of the 12th rib and follow the lower border of the rib anteriorly, ending at the
lateral border of the rectus muscle
Incision deepened through subQ, fascia down to the latissimus dorsi muscle and serratus
posterior inferior muscles from their anterior free borders, then the external and interior oblique
at their posterior free borders
Lumbosacral fascia identified, sharply incised well posteriorly, transversalis muscle then
identified, incised and split, exposing the peritoneum and pushed anteriorly
Posterior layer of the lumbosacral fascia is then incised from the anterior border of the
sacrospinalis muscle
Retractors applied
Perirenal fat is then separated from the underlying pelvic area of the kidney, and the posterior
surface id gently exposed
Upper ureter is identified and an identi-loop is wrapped around it, and connection with the
pelvis in the renal sinus is traced
Pelvis is incised open, and the lithiasis is extracted in oto
Flushing of the pelvocalyceal system done to expect remaining lithiasis
Hemostasis
Renal pelvis is repaired via continuous stich using chromic 4-0 sutures
Closed suction drain is placed around the pelvis and exteriorized separate from the incision
site, tube secured to the skin with sutures
Table is then broken to further coaptation of tissue edges
Closure layer by layer
Lumbodorsal fascia
prolene 0 continuous
Internal and external oblique
vicryl 0 continuous
Lastissimus dorsi, serratus posterior
vicryl 0 continuous
SubQ plain 2-0 simple interrupted
Skin
vicryl 3-0 subcuticular
Top dressing with Povidine iodine and operative sponges
End of procedure.

EXLAP
Patient positioned supine
Asepsis/antisepsis
Drapings done
Abdominal midline sutures removed up to the peritoneum
Abdomen explored, previous anastomotic site intact with no peri-anastomotic fluid collection
Dilated afferent loop from the previous gastro-jejunostomy and adjacent jejunum sutured
together with anchor sutures of silk 3-0
Jejuno-jejunostomy done with silk 4-0 sero-muscular layer sutured simple interrupted and
vicryl 4-0 mucosal layer sutured via Gambee technique
Adhesiolysis
Lavage done
Tube jejunostomy attachment to peritoneal wall secured
NGT (Fr 18 feeding tube) inserted and threaded to bypass the anastomosis
Hemostasis
Insertion of passive (Penrose) drain and placed on the anastomotic sites, exteriorized separate
from the incision site
Closure
Peritoneum rectus sheath using Prolene 0 continuous external retention sutures
Fascia using Prolene 0 simple with bumpers
Skin using silk 3-0 vertical mattress
Top dressing with Povidine iodine and operative sponges
End of procedure.

Laparoscopic Cholecystectomy
Patient positioned supine
Asepsis/ antisepsis
Drapings done
Incision is made in the umbilicus and dissected up to the level of the
peritoneum and opened
Hasson cannula is then inserted and carbon dioxide is insufflated and adequate
pneumoperitoneum is establish fixed, laparascope with the attached video
camera is passed through the umbilical port
Abdomen explored
Additional ports are then placed under direct vision; a 10mm port is placed in epigastrium, and
another 5 mm port in the midclavicular line, right

Thigh the lateral port, the gallbladder fundus was grasped and the hepatocystic triangle is
identified and dissected
Incisions freed using electrocautery
Cystic artery was identified and 2 proximal and 1 distal clips were applied
cystic artery was then cut
Cystic duct was identified and 2 proximal and 1 distal clips were applied,
cystic duct cut
Gallbladder freed from the liver bed using blunt and hot dissection
Hemostasis
Gallbladder was then delivered through the epigastric port
Closure of wound was then done using vicryl 2-0 on the fascia and nylon 3-0
subcuticular stitch on the skin
Top dressing with Povidine iodine and oprative sponges
End of procedure.

Lap converted to Open Cholecystectomy

Patient positioned supine
Induction of general anesthesia
Asepsis/ antisepsis
Drapings done
An incision is made in the umbilicus and dissected up to the level of the
peritoneum and opened
A Hassons cannula is then inserted and carbon dioxide is insufflated and adequate
pneumoperitoneum
Is establish, fixed, laparoscopic with the attached video camera is passes through the umbilical
part
Abdomen explored
2 additional ports are then placed under direct vision, a 10mm port is placed
the epigrastrium, and another 5 mm port in the midclavicular line, right
Through the lateral port, the gallbladder fundus was grasped and the hepatocystic triangle is
identified and dissected
Cystic artery was identified and 2 proximal and 1 distal clips were applied
Cystic artery was then cut
An aberrant vessel was then noted, after transecting the artery, and this produced brisk
bleeding in the operative field, the bleeder was identified but there was difficulty
in clamping due to the pooling of blood and inadequacy of the suction to clear the
hepatocystic triangle is identified
Laparoscopic surgery aborted
R subcostal Kochers incision is then made, traversing skin subcutaneous tissue,
anterior rectus sheath
Rectus muscle cut with electrocautery, and posterior rectus sheath,
pre-peritoneal fat, peritnoneum opened
Gallbladder and hepatoduodenal ligament exposed alier retractors were
placed and the GB fundus was lifted up
Betadine paint
Top dressing
End of procedure.

Cholecystectomy
Patient positioned supine
Induction of general anesthesia
Foley catheter insertion done
Asepsis/ antisepsis
Drapings done leaving operative site exposed
Transverse oblique, skin incision done over R subcostal area
Skin incision deepened exposing the gallbladder
Pls see above intra op findings
Hepatoduodenal peritoneum excise exposed & isolating the
cystic duct & Cystic artery
Cystic artery divided between 2 silk ligatures
Cystic duct isolated, divided between 2 silk ligatures
Gallbladder dissected form the liver bed, hemostasis
Washing with PNSS & suctioned out hemostasis
Peritoneum and posterior rectus approximated w/ vicryl 1, continuous running sutures
Anterior rectus fascia approximated w/ vicryl 1, continuous interlocking sutures
Fascia closed w/ plain 2-0 figure of 8 suturing
Skin closed w/ vicryl 4-0 subcutaneously
Betadine paint
Top dressing done
End of procedure

Chole, IOC, CBDE, T-Tube

Patient positioned supine
Induction of general anesthesia
Asepsis/ antisepsis
Drapings done
Midline incision done
Skin incision deepened up to the peritoneum
Retractors applied exposing the gallbladder and the anti-mesenteric
border of the bowel
Longitudinal incision of the fundus of the gallbladder the anti-mesenteric
boerder of the bowel
Anastomosis of the fundus of the gallbladder and anti-mesenteric border of the bowel sutured
in place using Conell suture
Isolated jejunum, anchored to the gastric wall of the fundus and sutured
Incision at the posterior gastric wall and proximal portion of the jejunum
Anastomosis of the proximal portion of the jejunum and the posterior portion of the gastric wall
and sutured in placing using Conell suture
Wedge biopsy of the pancreatic body tumor done
Ligation of blood vessels
Washing
Closure
Top dressing
End of procedure.

Puff Through
Patient positioned supine
Induction of general anesthesia
Asepsis/ antisepsis
Drapings done
Dilators serialty inserted up to maximum allowable size
Inscision made just above the dentate line, freeing the mucosal layer from
underlying muscle layer
Mucosa fixed accordingly while circumferentially freeing the mucosa
Portion of muscularis sent for frozen section biopsy
Mucosal tube dissected down to the perineum
Mucosa is freed from submuscusal layer
Bleeders controlled as encountered
Incision extending down to the level of colon
Biopsy done
Transition zone noted and dissected futher proximally just about the
same length as the mucosal tube
Portion of ganglionic segment of colon fixed to seromuscular cuff as it is circumferentially up to
the adequate level of colon
End to end anastomotic done of pulled through segment of colon and the mucosal layer of the
rectumat the level of thedentate line with interrupted stitch
Top dressing with Povidine Iodine and operative sponges
End of procedure.

Transverse Loop Colostomy

Patient positioned supine
Induction of general anesthesia
Asepsis/ antisepsis
Drapings done
RUO incision, transverse
A knuckle of transeverse colon was delivered into the wound, omentum
retracted upward
Omentum is divided over the presenting portion of the transeverse colon,
reflected to either side
Insertion of rubber catheter
Rubber catheter tip is cut off and one end inserted into the other point
Fat tabs on the loop of bowel were anchored to adjacent peritoneum
Peritoneal opening was partially closed by interrupted sutures
Skin and SubQ closed
Placement of colostomy bag
Dressing done
End of procedure.

LOW ANTERIOR RESECTION, STAPLED ANASTOMOSIS AND DIVERTING

ILEOSTOMY
Induction of anesthesia
Asepsis/Antisepsis
Drapings done leaving operative site exposed
Midline skin incision done 2cm above the umbilicus extending done
to the suprapubic area
Incision deepened to the peritoneum
Retractors applied (see intra-op findings)
Sigmoid & transverse colon mobilized small bowels walled off and
self-retaining retractors applied
Peritoneum of the pelvic colon is freed form region of the sigmoid down
to the other side
Peritoneum divided anteriorly to the rectum at the level of the base of the other side
Peritoneum further mobilized and surgeon passes R hands posteriorly
do to the hollow of the sacrum
Rectum freed posteriorly and anteriorly by blunt finger dissection
Blood supply to the distal segment of the inferior hemorrhoidal vessels &
inferior mesenteric artery ligated
Anastomosis clamped, applied below gross lower limits of the mass &
another clamp applied across previously prepared site proxima
l to the mass
Bowel divided between clamps
Lateral peritoneal attachment further divided from the left colon up to
transverse colon freeing the splenic flexure
Absorbable traction suture placed to serve as stay suture to the end of the
rectum and pursestring suture placed to closed end of the rectum
Pursestring suture tied snuggly around shaft of open stapler
Another pursestring suture applied at the end of the proximal sigmoid by
same technique used for rectal stump
Open end of the sigmoid gently manipulated over the end of the anvil
Assistant tightens clamp form below and surgeon form above prevents
fatty tissues form being trapped between lower ends
Assistant verifies if stapler is tightened to the correct thickness for height

ABDOMINOPERINEAL RESECTION
Patient supine in the lithotomy position
Anus is closed with silk 0 suture
Sterile field prepared
Low midline incision carried down to peritoneum
Exploration of entire peritoneal cavity
Mobilization of the sigmoid and descending colon by incising the peritoneal reflection of the left
paracolic gutter
Gonadal vessels separated and left ureter identified
Mobilization of distal part downward to the sacral promontory and the pre-sacral area
dissection to the rectovesical space continued
Incision made at the right side of the sigmoid mesocolon down to rectovesical pouch and right
ureter identified
Proximal sigmoid occluded with umbilical tape
Ligation of inferior mesenteric artery, just after take-off form the aorta and inferior mesenteric
vein

The lymphatic tissue in the pelvis removed with the specimen

Sharp and blunt dissection of the rectum up to the level of the tip of the coccyx
Lateral stalks divided, and ligated with 2-0 silk sutures
Lines of resection identified
Sigmoid colon transected, both cut ends closed to prevent spillage
Colostomy site prepared

Asepsis/antisepsis
Drapings done
Evacuation of fecal material
Dissection of hemorrhoidal pile from underlying sphincter muscles
Ligation of pedicle w/ slik suture
Cutting of pedicle
Closure by ______
Hemostasis
Betadine paint
Insertion of anal pack
Tight top dressing
End of procedure.

PERINEAL DISSECTION
Elliptical incision 3-4 cm anterior to the anal orifice and terminating at the tip of coccyx
Incision carried into perirectal fat
Perirectal fat incised down to the levator diaghragm
Anococcygeal ligament cut with cautery
Sharp division of Waldeyers fascia
Inferior and middle hemorrhoidal vessels ligated
Levator muscles opened upward beginning from below up to the region of the puborectalis
sling transected sigmoid specimen delivered through the perineal opening
Anterior part of the perineal dissection carried out
Prostate gland / posterior vaginal wall can be included in the specimen if necessary
Hemostasis
Washing with NSS
Perineum packed with gauze inside a glove
Skin closed with simple interrupted sutures
Colostomy matured to the skin
Hemostasis
Peritoneum in the pelvic area closed
Peritoneal washing
Complete count
Closure layer by layer
Peritoneum and fascia vicryl 0 continuous interlocking suture

LICHTENSTEIN TENSION-FREE HERNIOPLASTY R

EXCISION OF LIPOMA OF CORD
Induction of spinal anesthesia
Patient supine
Asepsis/antisepsis
Drapings done leaving operative site exposed
Oblique incision done at R groin
Dissection carried down to subcutaneous, internal and external oblique aponeurosis
Bleeders checked
Exposure and identification of vessels
Mesh applied to wall defect, floor repaired
Closure by layers
Subcuticular stiches done
Betadine paint
Top dressing
End of procedure.

Varicocelectomy
(Modified Ivanissevich Approach)
Oblique inguinal incision over external inguinal ring
External oblique aponeurosis divided
Spermatic cord isolated
Internal spermatic veins identified, isolated and ligated
(Suprainguinal Modified Palomo Approach)
Transverse incision 2 FB medial and FB (fingerbreaths) inferior to anterior superior iliac spine
and continued medially
Retroperitoneum entered, internal spermatic vein, identified, isolated, and divided between
ligatures
Location of incision, internal spermatic vein, identified on posterior aspect of peritnoneum,
isolated, divided between ligatures.

Circumcision
Induction of spinal anesthesia
Patient positioned supine
Oblique incision at R groin done
Dissection carried down to subcutaneous, internal and external oblique aponeurosis
Fascia opened
Floor repaired hemostasis
Closure layer by layer oblique aponeurosis

Subcuticular stich

Top dressing done

End of procedure.

HEMORRHOIDECTOMY
Induction of spinal anesthesia
Patient placed in dorsal lithotomy position

BELOW KNEE AMPUTATION

Patient supine
Asepsis/antisepsis
Drapings done leaving operative site exposed
Skin, subcutaneous tissue, and superficial fascia incised sharply in chosen configuration
Muscle bellies divided sharply/ electrocautery
Neurovascular bundle doubly clamped, divided and ligated with excessive traction avoided
Fibula divided 1cm proximal to the intended line of division of the tibia to form a conical shape
to the stump
Tibia divided perpendicular to its long axis with a hand or power bone saw
Posterior flap made
Anterior aspect of tibia rounded and beveled to avoid bony prominence in the stump
Wound irrigated with betadine wash
Muscles assessed for viability
Hemostasis
Simple myodesis approximating the calf muscles over the bone ends
Superficial fascia sutured with interrupted absorbable sutures
Skin approximated carefully
Dog ears carefully tailored
Suture line covered with sterile dressing
Immobilization using plaster splint
End of procedure.

PARTIAL HIP REPLACEMENT-LEFT (AUSTIN-MORE PROSTHESIS 445MM)

Induction of anesthesia
Patient positioned
Asepsis/Antisepsis
Drapings done
Posterolateral skin incision with midpoint at the level of greater trochanter
Sharp dissection to joint capsule
Exposure of capsule by opening the joint capsule
Removal of necrotic and frayed soft tissues
Removal of femoral head
Irrigation with plain NSS
Slight shortening of remaining femoral neck
Piece-meal resection of bone
Reeming of the intramedullary canal
Insertion of 45mm Austin-Moore prosthesis
Open reduction of acetabulum
Muscles apposed and sutured
Skin closure with vicryl 3-0 subcuticular stitch
Betadine paint
Top dressing done
End of procedure.

PARTIAL UNGEICTOMY
Patient positioned supine
Asepsis/antisepsis
Drapings done leaving the operative site exposed
Digital block on base (location, R or L)
Ingrone nail edge exposed, excised
Granulation tissue excised
Normal tissue and skin sutured
Betadine paint
Dressing done
End of procedure

EXCISION OF THYROGLOSSAL DUCT CYST

(SISTRUNK PROCEDURE)
Patient positioned supine
Induction of anesthesia
Asepsis/antisepsis
Transverse incision done just above the cricoid cartilage transversing the cyst
Incision deepened exposing the hyoid bone and the cyst
Cyst isolated from adjacent structure
Hyoid bone dissected ~1cm out to the chest
Direct traced up to the base of the tongue, ligated
Placement of drain
Closure done up to the skin
Betadine paint
Top dressing done
End of procedure.