Surgery mbbs help goood ism

1. Topic: Operative approache of
th5e organs Abdominal cavity

2. The operation for opening the
abdominal cavity is called
laparotomy.
They can be classified into
longitudinal
transverse
oblique
combined

3. Accesses to the abdominal cavity organs: 1 - Kocher's for liver and gallbladder surgery;
2 - according to Fyodorov; 3 - the transrectal to put in a gastrostoma; 4 - for sigmoid
colon surgery; 5 - the superior median laparotomic; 6 - the pararectal by Lennander; 7 -
according to Volkovych-Dyakonov for appendectomy; 8 - the inferior median
laparotomic

4. Longitudinal incisions
 The median laparotomy is the most
wide spread: superior and inferior
median laparotomy.
 The cut is done along the linea alba.
 This approach gives free access to
almost every organ without crossing
muscles, large vessels and nerves
of the abdominal wall.

5. A disadvantage of the technique
is a potential post-operational hernia,
especially after the superior laparotomy
where the linea alba is broad and thin.

6. Make an incision in the upper
abdomen to expose:
The gallbladder
Stomach
Duodenum
Spleen
Liver.

7. Use a lower abdominal incision
for patients with:
Intestinal obstruction
Pelvic problems.
Make an incision from the upper
to lower abdomen to:
Evaluate all abdominal organs
in a trauma laparotomy.

8.  Longitudinal incisions drawn through the
rectus sheath (transrectal) include
a paramedian cut, lead along the projection of
the internal border of the rectus muscle;
 the anterior lamina of its sheath is cut, the
rectus muscle is pulled outwards with a hook
 the posterior lamina of the sheath is incised
together with the parietal peritoneum.
 performed for operations in the superior
compartment

9.  the pararectal incision is
performed parallel to the
external border of the rec-tus
muscle while the muscle is
pulled inwards.
 - performed for organs which
localized in the inferior
compartment (mostly in
appendectomy).

10. Oblique incisions
 oblique incisions are applied in surgeries
for the liver and gall bladder or for the
spleen;
 the cut is done through all the layers
parallel to the costal arch.
 to access the vermiform process or
sigmoid colon, oblique cuts are made
parallel to the inguinal ligament;

11.  transverse cuts crossing or dilating
the rectus muscles are applied mostly
for gynecologic interventions;
 they provide a comfortable access to
the organs of the inferior compartment
of the abdominal and lesser pelvic
cavity;
 but they are used less frequently than
others due to difficulties in dilating the
access during an operation and in
suturing the rectus muscles as well;

12. Combined cuts
 combined cuts (thoracoabdominal)
provide a broad access to the
abdominal cavity organs including
those situated over the costal arches;
 they are applied in stomach resection,
splenectomy, liver resection, removal
of the adrenal gland, and other
operations;

13. Examine the abdominal
contents to confirm the
diagnosis.

14. At the end of the operation, close
the wound in layers. Use several
pairs of large artery forceps to hold
the ends and edges of the
peritoneal incision. Close the
peritoneum with a continuous 0
absorbable suture on a round-
bodied needle

15. Close the linea alba with
interrupted No. 1 polyglycolic
acid or continuous
monofilament nylon on a round
or trocar needle

16. Penetrating injuries
Penetrating injuries follow gunshot wounds
and wounds induced by sharp objects such as
knives or spears
Laparotomy with intra-abdominal
exploration is indicated when the abdomen
has been penetrated, regardless of the
physical findings
Signs of hypovolaemia or of peritoneal
irritation may be minimal immediately
following a penetrating injury involving the
abdominal viscera.

17. Blunt injuries
Blunt injuries result from a direct
force to the abdomen without an
associated open wound; they most
commonly follow road traffic
accidents or assaults
Following blunt injury, exploratory
laparotomy is indicated in the
presence of:
Abdominal pain and rigidity

18. RUPTURED SPLEEN
Technique
1.Place the patient supine on the operating
table with a pillow or sandbag under the left
lower chest. Open the abdomen through a
long midline incision. Remove clots from the
abdominal cavity to localize the spleen. If
bleeding continues, squeeze the splenic
vessels between your thumb and fingers or
apply intestinal occlusion clamps

19. 2.Make the decision whether to
remove or preserve the spleen.
If the bleeding has stopped, do
not disturb the area. If a small
tear is bleeding, try to
control it with 0 absorbable
mattress sutures

20. 3.To remove the spleen, lift it
into the wound and divide the
taut splenorenal ligament with
scissors.

21. 4.Ligate the short gastric
vessels well away from the
gastric wall. Dissect the
posterior part of the hilum,
identifying the tail of the
pancreas and the splenic
vessels

22. 5. If there is excess bleeding,
drain the bed of the spleen with
a latex drain brought out
through a separate stab wound.
Remove the drain at 24 hours, if
possible

23. LACERATION OF THE LIVER
Technique
1.Through a midline incision, examine the liver
and gallbladder. Small wounds may have stopped
bleeding by the time of operation and should not
be disturbed.
2.For moderate wounds or tears that are not
bleeding, do not suture or debride the liver. If a
moderate wound is bleeding, remove all
devitalized tissue and suture the tear with 0
chromic mattress stitches on a large round-
bodied needle

24. The intestinal suture is a basic element of most
operations for the gastroenteric tract.
 the suture must be firm, i.e. after the suture has
been put in, the edges of the sutured organs should
not loosen;
 the suture is to be hermetic in two meanings of the
term: mechanically hermetic so that no drop of an
organ's contents leak of its lumen, and biologically
hermetic so that no microflora ooze from an organ's
cavity;
 the suture must provide good hemostasis;
 the intestinal suture should not narrow the lumen of
a hollow organ;
 the suture should not hamper the peristalsis.

25. The Albert's two-row intestinal suture: 1 - Lembert's
serous-muscular suture; 2 - Czerny's through-out
interrupted suture

26.  The intestinal suture going through the
mucous and submucous layers is called
transfixed (Czerny's suture);

27. the two-row suture by Albert
The first row of sutures passes through all
the layers of the intestinal wall ensuring
firmness and mechanical hermeticity.
The second row of sutures, the serous-
muscular Lembert's suture, adds to its
biological her-meticity.

28. SMALL INTESTINE
Reducing the wound of the small intestine
If the intestinal wall has a small defect (up to 1
cm long), a one-row purse-string suture is put
in around the
In such case non-resoluble
suture material is used, and a
ligature is drawn only through
serous and muscular layer of
the intestinal wall.

29.  A needle should be inserted into serous
membrane, drawn through the muscular
membrane and taken out from serous one.
 the forceps is smoothly removed and the first
knot is completed. Then it is fixed by the
second (fixing) knot.

30. Resection
1 Determine the extent of the loop to be
resected, including a small margin of
healthy gut on either side. Hold up the
loop so that you can see the mesenteric
vessels against the light. Plan to divide
the mesentery in a V-fashion or separate
it from the intestinal wall, depending
upon the length of the mesentery.

31. 2.Isolate the mesenteric vessels by
making blunt holes in the
mesentery on either side of the
vessel. Doubly ligate each vessel
and then divide it between the
ligatures. Continue dividing the
mesentery until you have isolated
the section of gut to be resected.

32. 3.Apply crushing clamps to
both ends of the isolated loop
and gently "milk" the normal
bowel above and below the loop
to move contents away from the
planned point of resection

33. 4.Under the loop of bowel, place
a swab that has been
soaked in saline and wrung
out. Holding the knife blade
against one of the crushing
clamps, divide the gut.

34. 5.Clean the exposed part of the
lumen and discard the used
swab. Temporarily release the
occlusion clamp and check to
see whether the cut ends of the
bowel bleed freely

35. Intestinal anastomoses
Joining crossed areas of the intestine
is known as intestinal anastomosis.
These anastomoses are put in end-to-
end, side-to-side, end-to-side, and
side-to-end.

36. In a side-to-side anastomosis, two
completely closed stumps are first
made. To attain it, the free end of
the intestine is ligated and buried
into the purse-string suture. The
stumps are situated
isoperistaltical in relation to one
another; openings are made on
adjoining surfaces by a scalpel
and sutured by two rows

37. The side-to-side intestinal anastomosis after the small intestine resection. а - an
intestinal stump treatment: the ligated stump is buried into the purse-string suture; b -
suturing the anastomosis posterior lips with continuous blanket stitches; c - the initial
moment of suturing the anastomosis anterior lips; d - a glover's (Schmieden's) suture
put in to the anterior lips; e - the second row of Lembert's sutures put in the anterior
lips; f - the general view of the side-to-side anastomosis; repairing the edges of the
crossed mesocolon

38.  an end-to-end anastomosis joins the ends
of hollow organs directly by two-row Albert's
suture.
 the first row is transfixed, continuous or
interrupted suture with catgut; the second
row is interrupted serous-muscular
Lembert's sutures.
 for the large intestine a three-row suture is
used, the third row is of Lembert's sutures.
 such an anastomosis is more physiologic
and thus is widely applied in various
surgeries.

39. An end-to-side anastomosis is
applied when joining segments of the
gastroenteric tract of various
diameters - in the resection of the
stomach and joining the small
intestine with the large one

40. COLON
Treatment of colon injuries is dependent upon the
location:
Treat transverse colon injuries with exteriorization of
the site of injury as a colostomy
Treat left (descending) colon injuries with
exteriorization of the injury site through a colostomy;
drain the paracolic gutter and the pelvis
Treat right (ascending) colon injuries with resection of
the entire right colon; make an ileostomy and transverse
colostomy - do not attempt to repair the injury directly
An alternative in the treatment of colonic injury or
perforation is to defunction the lesion by creating a
colostomy or an ileostomy upstream from the lesion,
and placing a large latex drain near that lesion
Patients with colonic trauma require antibiotics.

41. Selecting the type of colostomy
Normally, a loop colostomy is the
easiest (Figure 6.48A)
If you have to resect a piece of
colon, perform a double-barrelled
colostomy with the two free ends
(Figures 6.48B)
palpation: it should admit the tip of
the thumb and finger (Figure 6.47).
Close the laparotomy incision.

42. Techniques
Determine the site for the
colostomy at surgery. Make an
incision separate from the main
wound in the quadrant of the
abdomen nearest to the loop to
be exteriorized. Use the greater
omentum as a guide to locate
the transverse colon.

43. Double-barrelled colostomy
1.Resect the gangrenous loop
of colon as described for
resection of the small intestine.
Mobilize the remaining colon so
that the limbs to be used for the
colostomy lie without tension.

44. 2.Bring the two clamped ends of bowel out
through a stab wound or gridiron incision
and keep them clamped until the
laparotomy incision has been closed
(Figure 6.53). Then remove the clamps and
fix the full thickness of the gut edge to the
margin of the stab wound. Approximate
mucosa to skin edge with interrupted 2/0
absorbable suture (Figures 6.54, 6.55). If a
bag is not available, cover the colostomy
with generous padding.

45. Witzel's gastrostomy: 1 - constructing the serous-muscular tunnel and burying the
tube into the purse-string suture; 2 - Position of a gastrostomic tube in the stomach
the tube are grabbed by the tool and drawn to the anterior abdominal wall through
the made-up opening. The tube is fixed to the skin by the threads brought o

46. The stomach resection by Billroth I (schematic) fact
excludes the possibility of peptic ulcers of the
gastroenterostomy. But it is not that easy to draw a
gastric stump to the duodenum. There must be no strain
of the ends while making an anastomosis because it
leads to lacerated sutures and to anastomotic leak.

47. The stomach resection by Billroth-II; 2 - the stomach
resection by Billroth-II in Hoffmeister-Finsterer's
modification

48. 1 - horizontal-bar stitches in liver ruptures
through an omentum; 2 - horizontal-bar
stitches with a blunt needle throughout an
omentum onto the liver's edge

49. . Cholecystectomy from the neck aspect: 1 - separating and ligating the vesical artery
and vein; 2 - separating the gallbladder out of its bed; 3 - the gallbladder's bed
peritonization target is to access the vascular pedicle and to compress the splenic
artery.

50. Thank you
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