Operative surgery

1. Operative Surgery
for MBBS oral examination
Department of General Surgery

2. Abscess Drainage
• Abscess is a collection of pus
• Pyogenic organisms
• It is an acute condition
• Has pain ,redness , warmth , Swelling
• There will be softening and fluctuation.
• Needs Incision and Drainage
• Anaesthsia ---local or general
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3. • Hilton’s rule followed
• Incision on the skin with 11 blade parallel to any
vital neurovascular plane
• Sinus forceps introduced and opened widely
parallel to neurovascular plane
• Pus drained , all loculi opened
• Cavity washed with saline
• Gently packed with wick gauze and dressed.
• Oral or iv antibiotics as necessary
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4. Where not to wait for fluctuation
• Palmar abscess
• Felon—pulp abscess
• Breast abscess
• Peri anal abscess
• Parotid abscesss

5. Any other option than I and D
• Repeated aspirations under ultrasound
guidance
• Being done in breast abscess
• Also in subphrenic abscess , liver abscess etc

6. Circumcision
• Excision of prepuce…..foreskin of penis
Indications:
• Phimosis
• Recurrent balanoposthitis
• Paraphimosis
• Excision biopsy of lesions of prepuce
• Religious ritual

7. How is circumcision done
• Anaesthesia---local lignocaine without
adrenalin OR general anaesthesia OR regional
anaesthesia.
• Dorsal slitting of prepuce made
• Outer skin and then inner skin is appropriately
incised cicumferentially and prepuce removed
• Hemostasis with mono polar diathermy
achieved . Absorbable suture ( catgut or vicryl
Rapide) used to approximate the two edges.

8. Surgery for Hydrocele
• Hydrocele is collection of fluid between the two layers
of tunica vaginalis testis
• Operations.
1. If the sac is thin and hydrocele is small-----Lord’s
plication after opening the sac
2. If slightly bigger ----Eversion of sac done
3. If larger Partial excision and eversion( Jaboulay’s
procedure ) done
4. Very large sac ---subtotal excision of sac an
hemostatic sutureof the edges done

9. Complications of hydrocele operations
• Hematoma collection
• Scrotal wall oedema
• Infection

10. Surgery for Inguinal hernia
• Hernia can be direct type or indirect type.
• There are many types of operations for it.
• The gold standard of operations is
Lichten stein’s Mesh repair
• Anaesthesia can be local, regional or general.
• After making a groin incision, inguinal canal
opened.
• Cord structures and hernia identified.

11. Hernia surgery --contd
• If indirect sac is there, sac opened, contents reduced,
neck transfixed and ligated
( herniotomy).
• Excess sac may be left behind or removed.
• Polypropylene mesh (white) is kept on the posterior
wall and fixed to inguinal ligament below and conjoint
above with polypropylene suture(blue).
• Laterally the mesh is slit to allow cord structures come
out.
• Then the wound is closed in layers.

12. • Laparoscopic hernia repair TEP ( totally extra
peritoneal) or TAPP transabdominal pre
peritoneal) procedures are now available.
• Better suited for bilateral repair.
• Needs special training and equipments.
• Modified Bassini’s procedure and many other
procedures are there for hernia repair

13. Appendicectomy
• Indications:
Acute appendicitis
Rarely mucocele of appendix

14. Types of appendicectomy
• Open procedure ( conventional)
• Laparoscopic procedure

15. Open appendicectomy
• To be done ideally within 48 hours of onset of
pain
• Grid iron incision made ( McBurney’s)
• Lanz incision may be more cosmetic
• External oblique, internal oblique and transversus
abdomis all opened along the direction of their
fibres
• Peritoneum opened.
• Any pus is sucked out

16. Appendicectomy --contd
• Caecum identified.
• Pulled up into the wound.
• Appendix identified.
• Picked with Babcock’s forceps.
• Mesoappendix and vessels therein are clamped
severally and ligated and cut.
• Appendix is thus skeletonised.
• Base is crushed , ligated and divided.
• Base may or may not be buried in the caecal wall

17. Appendicectomy --contd
• Hemostasis secured.
• A wash is given to the layers.
• Layers serially closed.

18. Difficulty in removing the appendix
• Rutherford Morrisons extension can be done
in which the muscles are cut laterally for
better access.

19. Complications of appendicectomy