operative atlas

In any operation

•• Indications Indications ..•• AnaesthesiaAnaesthesia ..•• Position of the patient Position of the patient ..•• Incision Incision ..•• Steps of the operation Steps of the operation ..•• Complications Complications ..

Abdominal operation

SupineSupine

I position for operation

Abdominal operation

TrendelenburyTrendelenbury

I position for operation

Abdominal operation

Lateral positionLateral position

I position for operation

Cross section of upper abdomenCross section of upper abdomen

Anatomy of Abdominal wall

Cross section of lower abdomenCross section of lower abdomen

Anatomy of Abdominal wall

Muscle & tendons of Muscle & tendons of abdominal wall abdominal wall ..

Anatomy of Abdominal wall

Muscle & tendons of Muscle & tendons of abdominal wall abdominal wall ..

Anatomy of Abdominal wall

Muscle & tendons of Muscle & tendons of abdominal wall abdominal wall ..

Anatomy of Abdominal wall

Muscle & tendons of Muscle & tendons of abdominal wall abdominal wall ..

Anatomy of Abdominal wall

Muscle & tendons of Muscle & tendons of abdominal wall abdominal wall ..

Anatomy of Abdominal wall

Muscle & tendons of Muscle & tendons of abdominal wall abdominal wall ..

Anatomy of Abdominal wall

Incision Planning

Adequate access Adequate access ..

Minimum damage Minimum damage ..

Strong and durable scar Strong and durable scar ..

LangerLanger’’s line in children s line in children ..

Abdominal incisions

Types of incisions

Midline incision

Midline incision

Repair of complete

burst abdomen

Midline incision

Paramedian incision

Paramedian incision

Paramedian incision

Paramedian incision

Paramedian incision (closure)

Skin Skin ..ExtExt. . oblique oblique apap..IntInt. . oblique moblique m..TransversusTransversus ..FF. . TrTr. + . + peritperit ..

Grid iron incision

Subcostal incision

Transverse upper Abdominal incision

Transverse upper Abdominal incision

Transverse lower Abdominal incision[Pfannenstiel]

Transverse lower Abdominal incision[Pfannenstiel]

Pulmonary Pulmonary ..Cardiovascular Cardiovascular ..

ShockShockHemorrhageHemorrhageDVTDVT

GITGIT..Vomiting Vomiting Abdominal distensionAbdominal distensionHiccoughHiccough

UrinaryUrinaryUraemiaUraemiaRetention of urineRetention of urine

Wound complicationWound complication

Post operation complication

HaematomaHaematoma & & SeromaSeroma ..

Infection Infection ..stitch sinus .Cellulitis .infected hematoma.

Surgical emphysema Surgical emphysema ..

Wound dehiscenceWound dehiscence (complete burst)(partial burst) .

Post operation wound complications

Cholecystectomy

Indications :

Chronic Chronic calcularcalcular cholecystitischolecystitis ..Acute Acute calcularcalcular cholecystitischolecystitis ((within 48 Hwithin 48 H.).)TrumaticTrumatic rupture rupture ..Malignant gall bladder Malignant gall bladder + + wedge of liver wedge of liver ..In hepatic resection In hepatic resection ..SymptomlessSymptomless gall stones in some casesgall stones in some cases

-- Diabetes - Big stones- non functioning gall bladder - calcified (porcalen) G.B.

Cholecystectomy

Ultrasound Ultrasound ..

IVC IVC ..

ERCP ERCP / / PTC PTC ..

Pre operative assessment of C.B.D.

Cholecystectomy

AnaesthesiaAnaesthesia

Position of patientPosition of patient((operative tableoperative table//imageimage))

Incision Incision ::-- SubcostalSubcostal-- RtRt paramedianparamedian

Cholecystectomy

Plain X ray

Radio opaqu

Gall stones

Ultrasound

Show gall stone with posterior shadow

Oral cholecystogram

Plain X ray

Calcified gall bladder

ERCP

Normal bile ducts

ERCP

Multiple

CBD stones

Sites of Towels

Missed CBD stone

T-tube still present

CutaneusExtraction of CBD stone through T. tube track

ComplicationsHaemorrhageHaemorrhageLiver failure due to hepatic ALiver failure due to hepatic A. . ligationligation ..Injury of bile ducts Injury of bile ducts ..

* Jaundice * Biliary peritonitis * Biliary fistula

Post Post cholecystectomycholecystectomy syndromesyndrome* stone missed* stricture CBD* Stump long* Symptoms due to other pathology

Cholecystectomy

Indications :

Acute appendicitis Acute appendicitis ((no massno mass) .) .

Recurrent or chronic AppRecurrent or chronic App. .

Carcinoma of appendix Carcinoma of appendix ..

CarcinoidCarcinoid tumor of appendix tumor of appendix ..

Appendectomy

AnaesthesiaAnaesthesia

Position Position

IncisionIncision-- grid irongrid iron-- RtRt paramedianparamedian-- lanzlanz transverse incisiontransverse incision

Appendectomy

Residual abscess Residual abscess ((pelvic or pelvic or subphrenicsubphrenic) .) .

FaecalFaecal fistula fistula ..

Paralytic Paralytic ileusileus ..

Wound infection Wound infection ..

Wound hernia Wound hernia ..

Post appendectomy complications

SplenectomyIndications :-

Rupture spleen Rupture spleen ..Conditions related to the spleen Conditions related to the spleen . .

- Cysts - Tumor- T.B - Abscess

SplenicSplenic artery aneurysm artery aneurysm ..With total With total gastrectomygastrectomy for cancer stomach for cancer stomach ..SplenomegalySplenomegaly with blood diseases with blood diseases ..

- cong. Spherocytosis- Haemolytic anemia (auto immune)- Hyper splenism- malarial spleen (Tropical)

In relation to portal hypertensionIn relation to portal hypertension- Hassab - Proximal spleno-renal shunt

End – side porta – caval anastmosis

End – side cavo – mesenteric anastmosis

H – graft Mesent. – caval anastmosis

Central spleno-renal anastmosis

Distal spleno-renal anastmosis(Warren shunt)

Haemorrage .Pancreatic injury .Gastric injury gastric fistula .Colonic injury colonic fistula .Left subphrenic collection & abscess .D. V. T.Burst abdomen due to wound sepsis .Infection specially in children .

Post splenectomy complications

NephrectomyIndications :-

Patient having transplant & his own kidney is infected or causing renal hypertension.Non functioning kidney (the other is normal) in association with :-

Hydronephrosis - Byonephrosisstones - ischemia

Trauma (inevitable)T.B. (resistant treatment)Tumors :

renal cell T. RadicalTr. Cell T. Nephro-uretrectomy

Unilateral renal hypertension if failed renal A. reconstruction .

NephrectomyAnaesthesiaAnaesthesia

Position Position

Incision Incision ::- Lumbar- Bed of 12th rib.- Anterior approach.

NephrectomyIn renal carcinoma :

More radical More radical kidney kidney + + perinephricperinephric fat fat + + supra renal Gsupra renal G..

LigationLigation of renal vein early of renal vein early ..

In In RtRt. . Side Side ((the vein is shortthe vein is short) ) open open IVIV..CC. . to remove tumor emboli to remove tumor emboli ..

ThyoridectomyIndications :-

Simple diffuse goitre + pressure .S. N. G. to avoid complications .Solitary Nodule .1 ry toxic goitre after medications .2 ry toxic goitre after medications .Malignant goitre .

Subtotal :-Bilateral removal leaving small parts .

Hemi thyroidectomy :-(Lobectomy) = entire lobe + isthmus .

Total thyoidectomy :-Rilat. Lobectomy + implantation of

parathyroid .Excision of isthmus

to relief pressure on trachea .

Types of Thyoridectomy

ThyroidectomyPosition Position

IncisionIncision

StepsSteps

Thyoridectomy

Complications

Thyroid crises .Haemorrhage .Respiratory obstruction due to oedema.Rec. L. nerve injury .Hypothyroidism .Hypoparathyroidism .Recurrent toxicosis

Inguinal Hernia Repair