Comments: Excellent paper. It’s obvious that you put quite a bit of work into this. Unfortunately, your paper needs adequate citations in the body of the text to meet our standards on plagiarism. You need to cite each textbook from your bibliography whenever you quote or use some information from the textbook or other resource. For example, writing (Jones 285) after the quote or information used means that you got it from the book whose author was Jones and the info came from page 285.
Laparoscopic cholecystectomy is a procedure in which laparoscopic techniques remove the gallbladder. It is the standard of care for symptomatic gallbladder disease, of which most are performed for symptomatic cholelithiasis. Other indications include acute cholecystitis, biliary dyskinesia, and gallstone pancreatitis.
Describe the reasons a patient might have the selected surgical procedure
The typical reason a cholecystectomy is a treatment of choice is inflammatory changes of gallbladder or blockage of bile flow by gallstones. Symptomatic cholelithiasis is the most common reason where gallstones in the gallbladder are blocking the bile flow and cause inflammation. The patient usually complains of episodic epigastric pain and right upper quadrant pain that radiates to the right shoulder. This pain is found to occur several hours after heavy meals and the patient experiences nausea, vomiting, bloating, fever, and right upper quadrant tenderness. Another condition is acute cholecystitis, where inflammation and symptoms are more prominent. The patient may have a fever, constant pain, positive Murphy's sign, or leukocytosis. Acute cholecystitis may be caused by calculous biliary tract disease with confirmed gallstones in the abdominal US. Acute acalculous cholecystitis usually occurs in critically ill patients, those with prolonged total parenteral nutrition, and some immunosuppressed patients. Patients with episodes of right upper quadrant pain (which are ‘classic' for biliary pain without evidence of cholelithiasis of US or ERCP) may also be referred for laparoscopic cholecystectomy. Gallstone pancreatitis (when small stones pass through the cystic duct) confirmed by cholangiography is another indication for laparoscopic cholecystectomy.
Describe the reasons a patient might be disqualified for this surgery and the options for the patient if any
A patient might be excluded for laparoscopic cholecystectomy due to acute general conditions that are a contraindication for any surgery such as an acute cardiac failure, uncontrolled hypertension, acute renal failure, pneumonia, etc. The condition should be treated by a primary care provider or specialist and the patient should be stable prior surgery. Additional contraindications may include the inability to tolerate general anesthesia, significant portal hypertension, uncorrectable coagulopathy, and multiple prior operations.
List the diagnostic tests and lab work that an attending surgeon might order and desc.
Comments Excellent paper. It’s obvious that you put quite a bit of .docx
1. Comments: Excellent paper. It’s obvious that you put quite a bit
of work into this. Unfortunately, your paper needs adequate
citations in the body of the text to meet our standards on
plagiarism. You need to cite each textbook from your
bibliography whenever you quote or use some information from
the textbook or other resource. For example, writing (Jones 285)
after the quote or information used means that you got it from
the book whose author was Jones and the info came from page
285.
Laparoscopic cholecystectomy is a procedure in which
laparoscopic techniques remove the gallbladder. It is the
standard of care for symptomatic gallbladder disease, of which
most are performed for symptomatic cholelithiasis. Other
indications include acute cholecystitis, biliary dyskinesia, and
gallstone pancreatitis.
Describe the reasons a patient might have the selected surgical
procedure
The typical reason a cholecystectomy is a treatment of choice is
inflammatory changes of gallbladder or blockage of bile flow by
gallstones. Symptomatic cholelithiasis is the most common
reason where gallstones in the gallbladder are blocking the bile
flow and cause inflammation. The patient usually complains of
episodic epigastric pain and right upper quadrant pain that
radiates to the right shoulder. This pain is found to occur
several hours after heavy meals and the patient experiences
nausea, vomiting, bloating, fever, and right upper quadrant
tenderness. Another condition is acute cholecystitis, where
inflammation and symptoms are more prominent. The patient
may have a fever, constant pain, positive Murphy's sign, or
leukocytosis. Acute cholecystitis may be caused by calculous
2. biliary tract disease with confirmed gallstones in the abdominal
US. Acute acalculous cholecystitis usually occurs in critically
ill patients, those with prolonged total parenteral nutrition, and
some immunosuppressed patients. Patients with episodes of
right upper quadrant pain (which are ‘classic' for biliary pain
without evidence of cholelithiasis of US or ERCP) may also be
referred for laparoscopic cholecystectomy. Gallstone
pancreatitis (when small stones pass through the cystic duct)
confirmed by cholangiography is another indication for
laparoscopic cholecystectomy.
Describe the reasons a patient might be disqualified for this
surgery and the options for the patient if any
A patient might be excluded for laparoscopic cholecystectomy
due to acute general conditions that are a contraindication for
any surgery such as an acute cardiac failure, uncontrolled
hypertension, acute renal failure, pneumonia, etc. The condition
should be treated by a primary care provider or specialist and
the patient should be stable prior surgery. Additional
contraindications may include the inability to tolerate general
anesthesia, significant portal hypertension, uncorrectable
coagulopathy, and multiple prior operations.
List the diagnostic tests and lab work that an attending surgeon
might order and describe the meaning of the results
The diagnostic tests are part of preoperative procedures and
ordered to rule out possible adverse health conditions that may
negatively affect surgery outcome. Diagnostics tests include
hematologic studies, lab work,
and images. Hematologic studies should include a complete
blood cell (CBC) count with differential, liver function panel,
amylase, and lipase. CBC may reveal polymorphonuclear
3. leukocytosis that is associated with acute cholecystitis or any
other inflammation of the gallbladder. In severe cases, mild
elevations of liver enzymes may be caused by inflammatory
injury of the adjacent liver. Patients with cholangitis and
pancreatitis have abnormal laboratory test values.
An acute increase in the level of liver transaminases (alanine
and aspartate aminotransferases), followed within hours by a
rising serum bilirubin level, is associated with
choledocholithiasis caused by acute common bile duct (CBD)
obstruction. Commonly the higher the bilirubin level, the
greater the predictive value for CBD obstruction. CBD stones
are present in approximately 60% of patients with serum
bilirubin levels greater than 3 mg/dL. It is recommended to
repeat testing over hours to days to evaluate patients with
gallstone complications. Improvement of the levels of bilirubin
and liver enzymes may indicate a spontaneous passage of an
obstructing stone. Conversely, rising levels of bilirubin and
transaminases with the progression of leukocytosis in the face
of antibiotic therapy may indicate ascending cholangitis with
the need for urgent intervention. Blood culture results are
positive in 30-60% of patients with cholangitis.
Another part of lab work is urine analysis to rule out infection
for urinary-genital tracts.
Diagnostic Images include abdominal radiography (XR),
ultrasonography (US), computed tomography scanning (CT),
magnetic resonance imaging (MRI), technetium-99m (99m Tc),
hepato-imino diacetic acid scintigraphy (HIDA scan),
endoscopic retrograde cholangiopancreatography (ERCP), and
percutaneous transhepatic cholangiography (PTC).
Abdominal XR is the part of a regular evaluation of gallbladder
diseases. The main role of plain films in evaluating patients
with suspected gallstone disease is to exclude other causes of
4. acute abdominal pain, such as intestinal obstruction, visceral
perforation, renal stones, or chronic calcific pancreatitis.
Upright and supine abdominal XR are occasionally helpful in
establishing a diagnosis of gallstone disease.
Ultrasounds (US) are very useful for diagnosing uncomplicated
acute cholecystitis and gallstone disease. It is the most
commonly used, most sensitive, and highly recommended
procedure. In addition, abdominal US is noninvasive,
inexpensive, simple, rapid, safe in pregnancy, and it does not
expose the patient to harmful radiation or intravenous contrast.
Gallstones appear as echogenic foci in the gallbladder. They
move freely with positional changes and cast an acoustic
shadow. The sonographic markers of acute cholecystitis include
gallbladder wall thickening (>5 mm), pericholecystic fluid,
gallbladder distention (>5 cm), and a sonographic Murphy sign.
The presence of multiple criteria increases its diagnostic
accuracy.
Computed tomography (CT) scanning is more expensive and
less sensitive than US for the detection of gallbladder stones,
though it is superior to US for the demonstration of gallstones
in the distal common bile duct. CT scanning is often used in the
workup of abdominal pain, as it provides excellent images of all
the abdominal viscera. CT can be used in diagnostic challenges,
for the detection of intrahepatic stones or recurrent pyogenic
cholangitis.
MRI is recommended as secondary imaging test when US does
not provide a definite diagnosis. Though MRI with magnetic
resonance cholangiopancreatography (MRCP) is an excellent
imaging study for noninvasive identification of gallstones
anywhere in the biliary tract, including the common bile duct,
it's costly and in need for sophisticated equipment and software.
5. HIDA scintigraphy is occasionally useful in the differential
diagnosis of acute abdominal pain, and it is highly accurate for
the diagnosis of cystic duct obstruction. HIDA is normally
taken up by the liver and excreted into bile, where it fills the
gallbladder and can be detected with a gamma camera. Failure
of HIDA to fill the gallbladder, while flowing freely into the
duodenum, is indicative of cystic duct obstruction. A non-
visualized gallbladder on a HIDA scan in a patient with
abdominal pain supports a diagnosis of acute cholecystitis.
ERCP permits radiographic imaging of the bile ducts. In this
procedure, an endoscope is passed into the duodenum and the
papilla of Vater is cannulated. Radiopaque liquid contrast is
injected into the biliary ducts, providing excellent contrast on
radiographic images. Stones in bile appear as filling defects in
the opacified ducts. Currently, ERCP is usually performed in
conjunction with endoscopic retrograde sphincterotomy and
gallstone extraction.
PTC may be the modality of choice in patients in whom ERCP
is difficult (e.g., those with previous gastric surgery or distal
obstructing CBD stone), in the absence of an experienced
endoscopist, and in patients with extensive intrahepatic stone
disease and cholangiohepatitis. A long large-bore needle is
advanced percutaneously and transhepatically into an
intrahepatic duct and cholangiography is performed.
List the incisions available to the surgeon and include their
advantages and disadvantages
There are several incisions could be applied by surgeon: midline
upper incision, paramedian incision, and subcostal incision. In
the case of a laparoscopic cholecystectomy, the surgeon
commonly performs small 25 mm incisions in midepigastrium,
umbilicus, and along the right costal margin insertion of four
trocars.
6. In midline upper incision surgeon going through the following
layers: skin, superficial fascia –fatty layer (Camper's fascia),
subcutaneous fat, superficial fascia – membranous layer
(Scarpa's fascia), fascia (linea alba), abdominal peritoneum.
In a paramedian incision, the surgeon goes through the
following layers: tissue layers of the skin, superficial fascia –
fatty layer (Camper's fascia), subcutaneous fat, superficial
fascia – membranous layer (Scarpa's fascia), anterior rectus
muscles, rectus fascia, abdominal peritoneum.
Subcostal - skin, superficial fascia –fatty layer (Camper's
fascia), subcutaneous fat, superficial fascia – membranous layer
(Scarpa's fascia), externa oblique muscle, internal oblique
muscle, transverses abdominis muscle, fascia, abdominal
peritoneum
Muscle layer – externa oblique muscle, internal oblique muscle,
transverses abdominis muscle
5) Describe other considerations to include anything else that
might help someone to understand the operation 6) Describe the
anatomy of the incisional layers as they relate to the selected
surgical procedure
Laparoscopic cholecystectomy is usually performed with 4
trocars: two 10 mm trocars in the midepigastrium and umbilicus
and two 25-mm trocars along the right costal margin. Some
surgeons use a 5-mm camera and trocar in the epigastrium, and
two or three port techniques have been described, but are not
the norm. Incisions are made through layers skin, superficial
fascia –fatty layer (Camper's fascia) subcutaneous fat,
superficial fascia – membranous layer (Scarpa's fascia), fascia
(linea alba), and abdominal peritoneum.
7. 7) Describe the anatomy and physiology of the structure that
will be actually removed or surgically modified
Cholecystectomy is surgical procedure of removal of the
gallbladder. The gallbladder is a thin-walled sac usually placed
between both hepatic lobes consisting of three anatomic parts:
the fundus, corpus, and infundibulum. The gallbladder ends in
the cystic duct that is a passive conduit that in humans has a
diameter of about 7 mm with a mucosa containing spiral valves
(valves of Heister). This duct drains into the common bile duct
without a sphincteric structure. The common bile duct courses
through the head of the pancreas ending in the sphincter of
Oddi, as it penetrates the duodenal wall where it forms the
ampulla of Vater.
The biliary tract is functionally integrated with the digestive
tract by neurohormonal mechanisms in the fasting and digestive
phases. The liver secretes bile continuously into the intrahepatic
ducts flowing into the extrahepatic ducts. The gallbladder is
filled with the aid of the sphincter of Oddi where the bile is
stored and concentrated in the fasting state and emptied during
all three phases of the digestive periods. In the interdigestive
period, about 10% of the hepatic bile can drain into the
duodenum occurring during intervals between the phasic
contractions of the sphincter of Oddi (diastolic periods) when
the secreted bile raises the ductal pressures above the sphincter
of Oddi basal pressures. The remaining 90% of bile is redirected
toward the cystic duct to be stored in the gallbladder. The entry
of bile distends the gallbladder by passive and active
mechanisms. During the fasting period, the gallbladder
maintains a moderate tonic contraction that is
superimposed with nonpropulsive and propulsive contractions.
In the digestive period strong gallbladder contractions and
8. sphincter of Oddi relaxation lead to the high rates of bile
discharge flowing into the common bile duct and duodenum.
8) Describe the related anatomical structures for selected
surgical procedure
The gallbladder is shaped like a pear, with its tip opening into
the cystic duct. The gallbladder is divided into three sections:
the fundus, body, and neck. The fundus is the rounded base,
angled so that it faces the abdominal wall. The body lies in a
depression in the surface of the lower liver. The neck tapers and
is continuous with the cystic duct, part of the biliary tree. The
gallbladder fossa, against which the fundus and body of the
gallbladder lie, is found beneath the junction of two hepatic
segments. The cystic duct unites with the common hepatic duct
to become the common bile duct. At the junction of the neck of
the gallbladder and the cystic duct, there is an out-pouching of
the gallbladder wall forming a mucosal fold known as
"Hartmann's pouch".
9) Describe the blood supply to and the drainage from the
structure. Where does it come from? How does it enter the
operative area and where is it located near and on the structure
itself?
The common hepatic artery, branch of the celiac trunk, supplies
blood to the liver and gallbladder along with the stomach, small
intestine, and pancreas. The common hepatic artery further
divides into three more branches, with the proper hepatic artery
supplying blood to the liver, gallbladder, and part of the
stomach. The common hepatic artery further bifurcates into the
left and right hepatic arteries to deliver blood the left and right
sides of the liver.
As the right hepatic artery approaches the gallbladder, it
branches off to form the cystic artery, which supplies the
9. gallbladder and cystic duct with oxygenated blood tissues of the
liver and gallbladder.
The cystic artery is usually branching out in the Calot's triangle
and has a variable length and enters the gallbladder in the neck
or body area. Although classically, the artery traverses the
triangle almost in its center, it can occasionally be very close or
even lower than the cystic duct.
It usually gives off an anterior or superficial branch and a
posterior or deep branch near the gallbladder. When the point of
dissection is very close to the gallbladder, surgeon may have to
separately ligate the two branches. Also, if the presence of a
posterior branch is not appreciated, it can cause troublesome
bleeding during posterior dissection. In addition, the cystic
artery gives of direct branches to the cystic duct.
There is the incidence of RHA variation that seems common
enough for description and may be as high as 50%. The RHA
normally courses behind the bile duct and joins the right pedicle
high up in the Calot's triangle. It may come very close to the
gallbladder and the cystic duct in the form of the ‘caterpillar' or
‘Moynihan's' hump. If
such a hump is present, the cystic artery in turn is very short.
In this situation the RHA is either liable to be mistakenly
identified as the cystic artery or torn in attempts to ligate the
cystic artery. The ensuing bleeding in turn predisposes to
biliary injury.
10) Describe the nervous supply as it relates to selected surgical
procedure
The hepatic nodes are responsible for the lymphatic drainage of
the region. Innervation of the gallbladder consists of
10. sympathetic fibers from the celiac plexus, parasympathetic
fibers from the vagus nerve (CN X) and sensory fibers from the
right phrenic nerve. Adrenergic and noncholinergic
nonadrenergic nerves mediate the active relaxation or
accommodation of the gallbladder that is gradually induced by
the incoming bile.
11) Describe how the patient is prepared in the Operating Room
for the surgery. Include such things as patient comfort
Preoperative preparation includes measures for prophylaxis
against deep venous thrombosis as sequential compression
devices and subcutaneously administered heparin. Another
measure of infection prophylaxis is administration of a first-
generation cephalosporin prophylactically. The stomach is
routinely decompressed with an orogastric tube after induction
of general anesthesia.
Positioning in the operating room is important for patient's
safety and surgery outcome. Patient's position is usually supine
on the operating table. The arms may be extended, or may be
tucked at the side. Tucking the right arm facilitates
intraoperative cholangiography, since there is less impediment
to positioning the C-arm.
The surgeon usually stands at the left side of the patient, while
the first assistant stands to the right. A second assistant may be
used on the surgeon's side to hold the laparoscopic camera. As a
rule, two monitors are used and placed on the right and left of
the patient near the head.
safety precautions, IV lines,
skin prep, draping, etc.
An orogastric tube is placed after induction of anesthesia. Most
11. surgeons place sequential compression stockings to avoid
venous stasis. Some surgeons place a Foley catheter in the
bladder, though urinary catheterization is rarely used.
12) Describe in detail the selected surgical procedure to
include:
a) Incision: Describe the incision layer-by-layer. Also explain
what the assistant would be doing. Opening Technique
During the trocar insertion, skin and subcutaneous tissue are
incised in a line over the linea alba. Small bleeding vessels,
"bleeders," are coagulated and Linea alba and extraperitoneal
fat are incised to the peritoneum. Peritoneum usually entered at
a point closest to the umbilicus to avoid injury to the bladder
below or the falciform ligament above.
b) Surgery: Describe the surgery step by step in detail. Your
research will have to be taken from books that teach the
procedure to surgeons which will help get the necessary depth
of understanding of the procedure that a well trained Surgical
Assistant needs.
Laparoscopic Cholecystectomy could be described in several
steps.
The surgeon places the first 10 mm trocar at the umbilicus.
After an infraumbilical incision is made, the open technique is
used to gain access to theperitoneal cavity and a 11 mm Hasson
port is secured to the fascia with a 0 Vicryl suture.
Pneumoperitoneum is set to a pressure of 15 mmHg.
The surgeon then inserts the laparoscope and performs a general
exploration of the abdomen. A 30-degree laparoscope allows
more flexibility in obtaining a complete view of all structures in
12. the portal area and decreases the risk of injury to the ducts.
The patient should be placed in reverse Trendelenburg position
and rotated on the operating table with the left side down.
Under laparoscopic visual control, the surgeon places two 5-mm
trocars along the right costal margin. The usual location is two
fingerbreadths below the costal margin at the midclavicular and
anterior axillary lines. These trocars should be approximately 8
to 10 cm apart. Exact position may need to be modified
depending upon patient habitus.
The fourth trocar will be the main operating trocar, so good
placement is crucial. The most common location for the fourth
trocar is epigastric, at least 10 cm from the laparoscope. The
trocar is placed under laparoscopic visual control and should be
directed to the right of the falciform ligament as it enters the
abdominal cavity.
Next step would be exposing Calot's triangle. Grasping forceps,
passed through the 5 mm ports by the assistant, are used to lock
and retract the fundus of the gallbladder in a lateral and
cephalad direction so that the entire right lobe of the liver is
retracted as well. A second 5 mm grasping forcep is used to
distract the infundibulum
laterally away from common bile duct and common hepatic bile
duct. The gallbladder may be immediately apparent or may be
surrounded by omental adhesions.
Adhesions to the underside of the liver and gallbladder may
contain omentum, colon, stomach, or duodenum and hence may
be dissected with care. Vascular adhesions may be divided with
hook cautery. Calot's lymph node overlying the cystic artery is
swept away, sometimes requiring brief cautery to obtain
hemostasis. If the gallbladder is acutely inflamed and tense, the
13. surgeon should decompress it before attempting to grasp it. The
surgeon passes a Veress needle through the abdominal wall
under laparoscopic visual control and uses the graspers (closed)
to lift the liver and elevate the gallbladder. The surgeon then
stabs the gallbladder with the Veress needle, connects the
needle to suction, removes the Veress needle and places the
fundoscopic grasper on the stab wound to hold it closed during
retraction.
After fundus of the gallbladder is exposed, the first assistant
grasps the fundus with an atraumatic locking grasper passed
through the most medial of the right subcostal ports. The
assistant pushes the gallbladder over the liver toward the right
shoulder, opening the subhepatic space and exposing the
infundibulum of the gallbladder.
The surgeon or assistant then places a second atraumatic grasper
on the gallbladder at its base. This grasper is generally also a
locking grasper, although some surgeons will prefer a
nonlocking grasper. Throughout dissection, the direction of
traction by this infundibular grasper is critical to prevent errors
in identification of the ductal structures in this area. Surgeon
retracts the infundibulum laterally to expose Calot's triangle. In
the two-handed technique, the surgeon retracts the infundibulum
with the left hand and dissects through the epigastric port with
the right hand. Alternatively, the assistant may control both
graspers and the surgeon maneuvers the camera with the left
hand.
The surgeon begins dissection directly adjacent to the
gallbladder and takes down any additional adhesions to the base
of the gallbladder sharply. The surgeon then identifies the
cystic duct, where it enters the gallbladder, so that the
gallbladder should be seen to funnel down and terminate in the
cystic duct.
14. Next step is to move the infundibular grasper backward and
forward, from side to side, so that the gallbladder-cystic duct
junction may be carefully delineated. A useful alternative
technique is the "fundus-first" or "top-down" technique, useful
for a severely inflamed gallbladder.
After dissecting omental adhesions away from the gallbladder,
the fundus is separated from the liver with a diathermy hook or
dissecting forceps, leaving a peritoneal rim with wich to grasp
and retract the liver cranially. Alternatively, a malleable
retractor can be placed through the lateral port to retract the
liver cephalad. The gallbladder is dissected away from the liver
edge with a blunt dissecting forceps or cautery hook or spatula.
If a stone is impacted in Hartmann's pouch, it may be dislodged
into the body of the gallbladder or removed by incising the
pouch on the side away from the duct and removing the stone so
that the entire circumference of the cystic duct-gallbladder
junction can be viewed.
Next step is to place a clip as close to the gallbladder as
possible and two similar clips on the cystic duct and leave
enough space between the sets of clips to make it possible to
divide the duct with scissors. It is important be careful not to
retract the cystic duct so forcefully that the clips impinge on the
cystic duct-common duct junction.
Then the surgeon’s assistant should reposition the infundibular
grasper to grasp the gallbladder adjacent to the cystic duct and
use this grasper to retract the gallbladder anteriorly and
laterally so that the surgeon can expose the cystic artery by
gentle spreading and dissecting with a Maryland dissector or
laparoscopic right-angle lamp. The cystic artery will be noted to
terminate by running onto the gallbladder, and visible
pulsations may be observed. Generally, 1 cm of length is
15. necessary for safe division.
The surgeon divides the cystic artery with clips, leaving a
minimum of two clips on the cystic artery stump. Division of
the cystic artery will generally permit the gallbladder to be
pulled farther away from the porta hepatitis by traction on the
infundibular grasper. When the gallbladder is dissected virtually
free from the liver bed but a few strands remain, inspect the
gallbladder bed and ducts for evidence of bleeding.
The surgeon’s assistant irrigates with saline, but takes care not
to suction directly on the cystic duct or artery stumps to prevent
clip dislodgment. After achieving hemostasis, surgeon divides
the remaining attachment of the gallbladder to the liver, places
a gallbladder grasper through one of the 10-mm trocars and
grasps the gallbladder at or near the cystic duct. The surgeon or
assistant removes the gallbladder from the abdomen, sometimes
using a specimen bag if the gallbladder is thick-walled or
infected. Frequently bile or stones must be aspirated from the
gallbladder before it can be withdrawn through the trocar site.
Open the gallbladder outside the abdominal wall and suction
bile from it.
After the gallbladder has been removed, the surgeon replaces
the epigastric trocar and inspect the surgical site for bleeding.
Irrigate the surgical field, and aspirate the irrigant from the the
subphrenic space and other areas.
If a drain is desired, it can be placed through one of the lateral
trocar sites. Pass an atraumatic grasper into the abdomen
through the lateral trocar. The surgeon’s assistant passes the
"outside" end of the drain into the abdomen through the
epigastric trocar, grasps the "outside" end of the drain and pulls
it out of the abdomen, along with the trocar, clamps the drain to
avoid loss of pneumoperitoneum, and positions the tip of the
drain in the subhepatic space.
16. c) Wound closure: Describe the wound closure layer-by-layer.
Describe the type of suture materials and needles are used.
Name the suturing techniques that are used and by whom. (ie:
running vs interrupted, simple vs complex)
Surgeon’s assistant removes the trocars and closes the wounds
in the usual fashion, injects the trocar sites with a long-acting
anesthetic to minimize pain and facilitate early discharge from
the hospital.
Each incision is irrigated with saline solution and closed in
layers. The fascia at the umbilical incision is closed with a 0
absorbable suture. The skin incision at each port site is closed
with a 0-4 subcuticular absorbable suture or skin staples.
Closing Technique
Peritoneum and fascia closed with 0 synthetic absorbable or
nonabsorbable suture
Subcutaneous tissue may be approximated with 2-0 absorbable
suture
Skin is closed with interrupted 4-0 nylon subcuticularly, or with
staples
Peritoneum closed separately with a continuous 2-0 absorbable
suture or incorporated with other layers Fascia closed with #0
or #1 braided nonabsorbable sutures placed 1 cm apart
Skin closed with 4-0 nylon, 4-0 subcuticular absorbable sutures,
or skin staples
d) Dressings/Drains: How is the wound dressed? How and where
17. are drains placed if applicable?
As part of postoperative care pneumatic compression devices
and/or subcutaneous heparin may be continued. Continued use
of antibiotics is at the discretion of the surgeon, although it is
usually not necessary. Patients are usually able to tolerate
liquids and solid food within 24 hours after operation. The
majority of uncomplicated cases are performed as outpatient
surgery with patients being discharged home the same day.
13) List the Bibliography to include: The name of the book,
name of the author(s), the pages referenced, the publish
1. Atlas of Minimally Invasive Surgery, 2005. Daniel B. Jones,
Benjamin E. Schneider, Shishir K. Maithel. Edition 1,
Publisher: Cine-Med, Inc. Woodbury, CT, USA
2. The SAGES Manual: Fundamentals of Laparoscopy,
Thoracoscopy and GI Endoscopy. 2006. 2nd Edition, Carol E.H.
Scott-Conner (Editor). Publisher: Springer, NY, USA
3. Current Diagnosis and Treatment Surgery 14/E / Edition 14.
2015. Gerard M. Doherty. Publisher: McGraw-Hill Professional
Publishing
4. Surgical Technology: Principles and Practice, 7e 7th Edition.
2005. by Joanna Kotcher Fuller. Publisher: Saunders Elsevier,
St. Louis, M