o

THYROIDECTOMY

o Patient supine with neck hyperextended

o Asepsis-antisepsis
o Sterile drapes placed
o transverse curved incision on skin crease or 2 cm above sternal notch, carried down to the platysma
o Upper flap created by subplatysmal dissection up to the notch of the thyroid cartilage in the midline of the
dissection
o Lower flap created by subplatysmal dissection up to suprasternal notch in the midline
o cervical fascia incised in the midline,
o cleavage plane created between the thyroid gland and the strap muscles,
o sternohyoid & sternothyroid muscle retracted laterally
o thyroid capsule dissected away from it on both sides.
o Mobilization and dissection

o LOBECTOMY
TOTAL
o Lobe retracted medially and anteriorly using one hand while dissecting posteriorly (close to the gland)
o middle thyroid vein ligated
o superior thyroid artery and vein ligated close to the gland to avoid ligation of superior laryngeal nerve.
o recurrent laryngeal nerve identified and spared
o parathyroids identified and spared
o inferior thyroid artery ligated
o lobe and isthmus dissected from the tachea, and remove
o pyramidal lobe removed when present
o Hemostasis
o
PARTIAL (subtotal) THYROIDECTOMY
o multiple hemostats applied at the thyroid parenchyma
o gland transected
o suture ligation of the thyroid parenchyma and surface veins.
o segment approximated to the trachea
o Hemostasis
o Lavage or irrigation
o Drain (rational placement)
o Correct count
o
WOUND CLOSURE:
o strap muscles apposed at midline, chromic 2-0
o platysma muscles apposed, dermis apposed,
o subcuticular suturing of skin with vicryl 4-0
o light dressing

PAROTIDECTOMY

o Patient supine, head turned to the contralateral side with neck hyperextended
o ASEPSIS/ANTISEPSIS done
o STERILE DRAPES PLACED
o the lateral angle of the eye and labial commisure uncovered
o Modified Y incision making a vertical pre- and
o postauricular incisions united approximately at the angle of the mandible, forming a Y which converge with a
transverse incision 3 cm below the mandible
o deep incision made into the superficial cervical fascia
 o (anteriorly: fat and platysma ; posteriorly: fat only)
o FLAP formation:
o skin and fat elevated using scalpel, sharp and blunt dissection upward, medially, laterally, downward, and
posteriorly.
o UPPER FLAP: traction provided upward and medially on the dissected skin, and laterally toward the external
auditory canal.
o LOWER FLAP: dissection of the skin downward and posteriorly toward the mastoid process
o may sacrifice the great auricular nerve and the posterior facial vein, which are both very closely situated in the
vicinity of the lower flap and the lower parotid border

FACIAL NERVE IDENTIFICATION:

o distal phalanx of the left index finger placed on themastoid, pointing to the eye of the patient
o parotid fascia incised carefully & the superficial lobe of the parotid mobilized
o hemostat inserted between the mastoid and the gland
o main trunk of the facial nerve exposed at a depth of about 1.5 cm. from the external surface of the mastoid
process by dissecting directly downward along the anterior border of the mastoid process above the attachment
of the posterior belly of the digastric muscle.

o
RESECTION OF THE SUPERFICIAL LOBE
o with gentle traction of the gland
o further anterior nerve dissection toward the periphery of the gland,
o the superficial lobe totally mobilized and resected Stensen’s duct encountered as the dissection carried toward
the ends of the branches of the facial nerve
o duct then ligated and divided
o
RESECTION OF THE DEEP LOBE
o deep lobe removed carefully, working under the
o facial nerve by the piecemeal dissection technique.
o Hemostasis

o Complete removal of the parotid gland reveals the ff structures: (acronym VANS)
o vein: internal jugular
o arteries: external and internal carotid
o nerves: IX, X, XI, XII
o anatomic entities starting with “S”:styloid process; muscles: styloglossus, stylopharyngeus, stylohyoid

o LAVAGE or IRRIGATION
o DRAIN (rational placement)
o CORRECT COUNT
o WOUND CLOSURE: platysma muscles apposed,
o dermis apposed,
o subcuticular suturing of skin with absorbable suture
o LIGHT DRESSING
o the contralateral side
o Skin incision created from the inferior border of mastoid going down along sternocleidomastoid muscle and
curved as a low collar curvilinear insicion
o Superior flap created
o Incision made starting below at the anterior edge of the sternocleidomastoid muscle, then along the anterior
edge of the superior belly of the omohyoid muscle to the hyoid bone
o Space anterior to the sternocleidomastoid muscle opened, exposing the carotid sheath
o posterior edge of the sternocleidomastoid muscle opened
o Subclavian vein, the thoracic duct on the left side and the accessory duct on the right side preserved
o Transection of sternocleidomastoid muscle
 o Ligation of external juguIar with distal suture ligature and a proximal tie, then transected
o Sternocleidomastoid muscle reflected upward, using blunt and sharp dissection
o Carotid sheath opened
o Ansa hypoglossi is transected
o Dissection of internal jugular vein off the internal carotid artery and vagus nerve
o Suture-ligation with 1-0 silk then division of internal jugular vein in between ligatures
o Dissection carried upward following the plane formed by the anterior edge of the superior belly of the
omohyoid muscle
o Inferior belly of omohyoid transected
o Superior belly of the omohyoid muscle detached from the hyoid bone
o Preservation of phrenic nerve
o Spinal accessory nerve transected and with associated lymph nodes reflected upward
o External maxillary artery and anterior facial vein transected at the mandibular edge. Including in the dissection
the pre- and retrovascular lymph nodes
o Dissection of submental triangle, crossing the midline to the opposite anterior belly of the digastric muscle
o The nodes, fat, and fascia reflected downward over the anterior belly of the digastric muscle
o Identification and preservation of strap muscles
o Fibrofatty tissue of the posterior triangle of the neck dissected forward and downward in a plane immediately
lateral to the fascia of the splenius and the levator scapulae muscles
o Removal of all the contents of the posterior triangle
o Spinal accessory nerve and the transverse cervical vessels divided
o Preservation of the branches of the cervical plexus
o Dissection of internal jugular vein
o Dissection of the Submandibular Triangle
o Exposure & preservation of ramus mandibularis
o Exposure & transection of the facial vessels
o Dissection of submandibular prevascular and retrovascular lymph nodes into the specimen area
o Division of lingual nerve and the submandibular gland duct
o Preservation of hypoglossal nerve and the accompanying veins
o Ligation & division of Wharton duct and tributaries of the lingual vein
o hyoglossus muscle from deep plane of dissection, while the digastric and stylohyoid muscles form the inferior
plane
o Posterior belly of the digastric and stylohyoid muscles removed with the contents of the dissection
o The muscle and lymph node mass reflected upward to the point at which the internal jugular vein immobile
o Internal jugular vein clamped at this point and tied with 2-0 silk passed about the vessel
o A fine silk suture ligature then placed distally. Distal to the suture ligature free tie secured, and the vessel cut
between the two distal ligatures
o External maxillary artery ligated and transected
o Tail of parotid transected along with the attachments of sternocleidomastoid muscle
o Transection & ligation of facial vein
o Completion of the dissection
o Thorough irrigation with saline
o Placement of suction drains
o A two-layer closure
o Continuous 4-0 vicryl for the approximation of the platysma muscle and subcuticular suture for the skin
o Light dressing

MODIFIED RADICAL MASTECTOMY

o Patient positioned with ipsilateral arm abducted in 90º on an arm board and place a folded sheet, about 5 cm
thick under the patients scapula and posterior hemithorax
o Asepsis/ Antisepsis done
o Sterile drapes placed
 o Using a sterile marking pen, circle drawn 2-3 cm away from the perimeter of the primary tumor. In addition to
the area of skin outlined by the circle drawn around the tumor include the entire areola and nipple in the patch
of skin left on the specimen.
o Incision chosen that would have the least tension on closure, either elliptical, vertical etc.
o Incision made through all the layers of the skin
o Hemostasis obtained by applying electrocoagulation to each bleeding point
o Use electrocautery for the formation of the upper and lower flaps
o Dissection of the breast began medially. Pectoralis fascia elevated
o Arterial perforators entering the breast ligated with vicryl 2-0
o The clavipectoral fascia opened, for access to the axilla. Pectoralis major and minor protected.
o Axillary vein and its tributaries identified. Ligation of all the tributaries toward the breast with 3-0 or 4-0 silk.
o Brachial plexus and axillary artery protected
o Using a scalpel or metzenbaum scissors, axillary contents of fat and lymph nodes evacuated, pushing them
towards the breast in continuity
o Five nerves should be identified and protected if possible
o long thoracic nerve- innervating the serratus anterior muscles, if injured caused winged deformity
o thoracodorsal nerve- innervates the latissimus dorsi muscle
o medial anterior thoracic-lateral to the pectoralis minor muscle
o lateral anterior thoracic-medial edge of the pectoralis minor
o subscapular
o Hemostasis
o Irrigation
o Complete count
o Two Jackson-pratt drains placed; the first to drain the inferior skin flap and the axilla, and second to drain the
superior skin flap. Close the subcutaneous tissue with interrupted 3-0 vicryl and close the skin with vicryl 4-0
subcuticularly
o Dry sterile dressing

TOTAL MASTECTOMY
o Same as modified radical mastectomy without the axillary dissection

WIDE EXCISION WITH AXILLARY DISSECTION

o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o cosmetic incision elliptical incision. Remove the tumor and healthy mammary tissue and send it to lab for frozen
section
o Transverse incision at the lower axilla.
o Both pectoralis muscles retracted.
o Axillary vein identified at the medial area of the pectoralis minor and tributaries ligated.
o Thoracodorsal nerve protected, identified closed to the ant margin of the latissimus dorsi muscle and the long
thoracic nerve, under the fascia of the serratus anterior muscle.
o Dissection completed and specimen separated from the axillary vein.
o Axillary cavity drained with Jackson pratt
o Hemostasis
o Complete count
o Wound closure

EXCISION OF BRANCHIAL CLEFT CYST

o Patient supine, head turned to the contralateral side with neck hyperextended
o Asepsis-antisepsis
o Sterile drapes placed
 o A small transverse incision done above the cyst; around a sinus an elliptical incision made.
o Multiple incisions if the cyst or sinus is low
o sternocleidomastoid muscles separated and elevated, always using the medial border
o carotid sheat and hypoglossal nerve visualized
o dissection of the cyst or sinus cephalad toward the pharyngeal wall
o HEMOSTASIS
o LAVAGE or IRRIGATION
o CORRECT COUNT
o WOUND CLOSURE

EXCISION OF THE THYROGLOSSAL DUCT CYST

o Patient supine with neck hyperextended

o Asepsis-antisepsis
o Sterile drapes placed
o transverse incision over the cyst.
o superficial fascia (fat and platysma) incised
o Formation of the flaps: the upward elevation reaching the hyoid bone and extending cephalad 1-2 cm.
o Lower flap elevated almost to the isthmus of the thyroid gland
o Cyst dissected and isolated with a small hemostat and scissor. The involved anatomical entities depend upon the
location of the cyst: suprahyoid (rare), hyoid (common), infrahyoid or suprasternal (rare).
o Special care taken of the hyoid bone and tract.
o Central part of the hyoid bone cleaned.
o Some cuffs of sternohyoid and mylohyoid left attached to the bone, as well as some cuffs of the underlying
geniohyoid and genioglossus attached to the cephalad tract.
o Curved hemostat inserted under the central part of the hyoid bone. With heavy scissors or small bone
cutter, bone cut on both sides.
o Upward dissection continued bilaterally to the midline where the tract is located
o Thyrohyoid membrane now exposed

o The foramen cecum also requires special attention. The anesthesiologist’s index finger is inserted into the
patient’s mouth, elevating the foramen cecum. With continous cephalad dissection, one reaches the foramen
cecum by palpating the finger of the anesthesiologist just under the thyrohyoid membrane.
o Foramen cecum excised in continuity and the defect closed with figure-of-eight 4-0 chromic catgut or any other
absorbable suture.
o HEMOSTASIS
o LAVAGE or IRRIGATION
o CORRECT COUNT
o Reconstruction. Midline approximation performed of the mylohyoid and sternohyoid with interrupted sutures
o WOUND CLOSURE

EXCISION OF CYSTIC HYGROMA

o Patient supine, head turned to the contralateral side

o Adequate transverse incision above the cyst
o Skin and fat carefully elevated using a knife
o Sharp and blunt dissection upward, and downward
o Careful sharp dissection, usually employing a no. 15 blade supplemented with blunt dissection
o Extensions into various tissue planes and between muscle and nerve bundles, followed, exposed and removed
to effect a complete cure
o HEMOSTASIS
 o LAVAGE or IRRIGATION
o DRAIN (rational placement)
o CORRECT COUNT
o WOUND CLOSURE

TRACHEOSTOMY

o Patient supine with neck hyperextended

o Asepsis-antisepsis
o Incision two finger breadths above the sternal notch
o children: vertical incision to avoid injury of the arteries and veins located under the anterior border of
SCM
o adult: vertical or transverse incision
o incision through the cervical fascia in the midline,
o extended to expose the full length of the strap muscles
o thyroid isthmus and thyroidea ima identified & ligated
o anterior wall of the trachea below the isthmus cleaned
o anterior tracheal wall mobilized and elevated using a hook at the lower border of the cricoid cartilage
o vertical incision through the 2-3 tracheal ring.
o cricoid cartilage and 1st tracheal ring prtected to avoid postoperative tracheal stenosis
o tracheal opening widened with a tracheal spreader
o Hardy-shiley tracheostomy tube inserted as the endotracheal tube is slowly backed out
o Hemostasis
o correct count
o The tube secured with umbilical tape around the patient’s neck.
o Iodoform packed in the subcutaneous tissue around the tracheostomy tube

RIGHT HEMICOLECTOMY

o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Exploration of the entire peritoneal cavity
o Mobilization of the right colon by incision of the right paracolic peritoneal reflection from distal ileum
o down to the transeverse colon.
o Renocolic and hepatocolic ligaments divided
o Duodenum protected
o gonadal vessels separated and right ureter identified
o Lines of resection identified
o Terminal ileum and transverse colon occluded with umbilical tape.
o ileocolic pedicle ligated.
o right branch of middle colic pedicle ligated
o distal ileum and transverse colon divided just after the hepatic flexure
o viability of the cut segments checked
o Bowel edges painted with betadine
o Resection of the mesentery down to the root
o Two- layer end to end anastomosis (ileocolic) using an interrupted silk 4-0 (Connel technique) and
interrupted silk 4-0 (Lembert technique) for the seromuscular layer
o Anastomosis checked for leakage
o mesenteric decfect clsoed with Chromic 2-0
o Hemostasis
o Peritoneal washing
 o Complete count
o Closure layer by layer
o Peritoneum and fascia – Vicryl 0 continuous interlocking suture
o Skin – Silk 4-0

LEFT HEMICOLECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Exploration of the entire peritoneal cavity
o left colon from sigmoid to left transverse colon mobilized by incising the peritoneal reflection of the left
paracolic gutter.
o Splenocolic, renococolic and pancreaticocolic ligaments divided
o Gonadal vessels separated and left ureter identified
o Distal transverse colon and sigmoid colon occluded with umbilical tape
o Ligation the inferior mesenteric artery at its take off from the aorta and the inferior mesenteric vein
o Lines of resection identified
o proximal sigmoid divided followed by the left transverse colon just before the splenic flexure
o viability of the cut segments checked
o Bowel edges painted with betadine
o Resection of the mesentery down to the root
o Two- layer end to end anastomosis using an interrupted silk 4-0 (Connel technique) and interrupted silk
4-0 (Lembert technique) for the seromuscular layer
o Anastomosis checked for leakage
o Mesenteric defect closed with chromic 3-0
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia – Vicryl 0 continuous interlocking suture
o Skin – Silk 4-0

TRANSVERSE COLECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Exploration of the entire peritoneal cavity
o Gastrocolic ligament releasedfrom the hepatic to splenic flexure
o Hepatic and splenic flexure released
o Transverse colon occluded with umbilical tape
o Middle colic artery and vein ligated
o Lines of resection identified
o Transverse colon divided at the hepatic and splenic flexure
o Viability of the cut segments checked
o Bowel edges painted with betadine
o Resection of the mesentery down to the root
o Two- layer end to end anastomosis using an interrupted silk 4-0 (Connel technique) and interrupted silk
4-0 (Lembert technique) for the seromuscular layer
o Anastomosis checked for leakage
o Mesenteric decfect closed
o Hemostasis
 o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia – Vicryl 0 continuous interlocking suture
o Skin – Silk 4-0

SIGMOID COLECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Low midline incision carried down from skin to peritoneum
o Exploration of the entire peritoneal cavity
o Left colon carefully mobilized from rectosigmoid to descending colon by incising the peritoneal
reflection of the paracolic gutter
o Splenocolic and renocolic ligaments divided
o Gonadal vessels separated and left ureter identified
o Sigmoid colon occluded with umbilical tape
o Incision made at the right side of the sigmoid mesocolon down to the distal sigmoid
o Inferior mesenteric artery ligated just after take off from the aorta and the inferior mesenteric vein
o Lines of resection identified
o proximal sigmoid divided followed by the distal sigmoid
o Bowel edges painted with betadine
o Check for the viability of the cut segment
o Resection of the mesentery down to the root
o Two- layer end to end anastomosis using an interrupted silk 4-0 (Connel technique) and interrupted silk
4-0 (Lembert technique) for the seromuscular layer
o Anastomosis checked for leakage
o Mesenteric decfect closed
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia – Vicryl 0 continuous interlocking suture
o Skin – Silk 4-0
o Dry sterile dressing

ANTERIOR RESECTION
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Low midline incision carried down from skin to peritoneum
o Exploration of the entire peritoneal cavity
o Mobilization of the left colon from descending to rectosigmoid colon by incision of the peritoneal
reflection of the left paracolic gutter down to the sacral promontory
o gonadal vessels separated and left ureter identified
o dissection continued to the rectovesical space
o right ureter identified by an incision at the right side of the sigmoid mesocolon down to rectovesical
pouch
o inferior mesenteric artery ligated just after take off from the aorta and the inferior mesenteric vein
o Lines of resection identified
o Divide the proximal sigmoid followed by the rectosigmoid segment
o Bowel edges painted with betadine
o viability of the cut segment checked
 o Resection of the mesentery down to the root
o Two- layer end to end anastomosis using an interrupted silk 4-0 (1st layer) and interrupted silk 4-0
(Lembert technique) for the seromuscular layer
o Anastomosis checked for leakage
o mesenteric defect closed
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia – Vicryl 0 continuous interlocking suture
o Skin – Silk 4-0

TOTAL COLECTOMY
o Patient supine
o Sterile field prepared
o Midline incision carried down from skin to peritoneum
o Exploration of the entire peritoneal cavity
o Mobilization the right colon by incising the right paracolic peritoneal reflection from distal ileum down
to the transverse colon.
o Right renocolic and hepatocolic ligaments divided
o Duodenum protected
o gonadal vessels separated and right ureter identified
o Mobilization the left colon from sigmoid to left transverse colon by incising the peritoneal reflection of
the left paracolic gutter.
o Division of the splenocolic, renococolic and pancreaticocolic ligaments
o gonadal vessels separated and left ureter identified
o gastrocolic ligament released
o hepatic and splenic flexure released
o Ligation of the lymphovascular pedicles starting from the ileocolic, right colic, middle colic and inferior
mesenteric vessels
o Mesenteric dissection
o Mobilization of distal part downward to the sacral promontory and the pre-sacral area
o Lines of resection identified
o Distal ileum transected followed by transaction ofthe proximal rectum
o Two- layer end to end anastomosis (ileorectal) using an interrupted silk 4-0 (1st layer) and interrupted
silk 4-0 (Lembert technique) for the seromuscular layer
o Anastomosis checked for leakage
o mesenteric defect closed
o Hemostasis
o Peritoneal washing
o Complete count
o Closure layer by layer
o Peritoneum and fascia – Vicryl 0 continuous interlocking suture
o Skin – Silk 4-0

TRANSVERSE/ SIGMOID LOOP COLOSTOMY

o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Transverse incision over right or left upper quadrant for transverse and left lower quadrant for sigmoid
o Division of the anterior rectus sheath
o rectus abdominis muscles retracted
o posterior rectus sheath and peritoneum divided
 o Exteriorization of transverse/sigmoid colon into the wound
o exteriorized bowel sutured to the fascia with silk 4-0
o small hole created at the mesenteric border of the colon and plastic rod inserted
o colon opened and matured to the skin with 4-0 vicryl sutures
o Cover the colostomy with wet gauze

CLOSURE OF COLOSTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile field prepared
o Colostomy occluded with gauze
o Elliptical incision around the colostomy
o Mobilization of the colostomy from subcutaneous fat down to fascial attachments
o Peritoneal cavity opened
o colon released from adhesions in the peritoneal cavity
o colon debrided or resected if needed
o Two- layer anastomosis using an interrupted silk 4-0 (1st layer) and interrupted silk 4-0 (Lembert
technique) for the seromuscular layer
o Anastomosis checked for leakage
o Hemostasis
o Complete count
o Wound closure
o Peritoneum and fascia – Vicryl 0 continuous interlocking suture
o Subcutaneous tissue and skin - open

ABDOMINOPERINEAL RESECTION
o Patient supine in the lithotomy position
o Anus is closed with silk 0 suture
o Sterile field prepared
o Low midline incision carried down to peritoneum
o Exploration of entire peritoneal cavity
o Mobilization of the sigmoid & descending colon by incising the peritoneal reflection of the left paracolic
gutter
o Gonadal vessels separated and left ureter identified
o Mobilization of distal part downward to the sacral promontory and the pre-sacral area
o dissection to the rectovesical space continued
o incision made at the right side of the sigmoid mesocolon down to rectovesical pouch and right ureter
identifed
o Proximal sgmoid occluded with umbilical tape
o Ligation of inferior mesenteric artery, just after take off from the aorta and the inferior mesenteric vein
o The lymphatic tissue in the pelvis removed with the specimen
o Sharp and blunt dissection of the rectum up to the level of the tip of the coccyx
o Lateral stalks divided, and ligated with 2-0 silk sutures
o Lines of resection identified
o Sigmoid colon transected, both cut ends closed to prevent spillage
o Colostomy site prepared

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

HEMORRHOIDECTOMY
o Patient in a lithotomy position
o Sterile field prepared
o anal dilatation and anoscopic evaluation performed
o gauze sponge inserted into the lower rectum
o hemorrhoids identified
o hemorrhoids with hemorrhoidal clamp
o Suture ligation of feeding vessel
o elliptical incision over anoderm including skin tag made
o Submucosal dissection of hemorrhoidal tissue down to the internal sphincter muscle
o Hemorrhoid drawn away from the sphincter with blunt dissection
o hemorrhoidal mass dissected and divided with electrocautery
o hemorrhoidal pedicle oversewn with a running lock-stitch of chromic 2-0 until entire defect has been closed
o Achieve complete hemostasis
o Light dressing

FISTULOTOMY/FISTULECTOMY
o Patient in a lithotomy position
o Sterile field prepared
o anal dilatation and anoscopic evaluation performed
o external openings of the fistula identified
o probe inserted into fistulous tract while anal canal palpated to identify the external opening
o soft tissues overlying the tract divided and part of the margin excised to convert the deep slit-like defect
into a V-shaped defect
o All tracts kept fully opened
o Hemostasis
o Dry sterile dressing

APPENDECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile field prepared
o Transverse incision at the right lower quadrant carried down from skin up to subcutaneous tissue
o Fascia cut obliquely
o Muscle splitting done
 o Peritoneum grasp with hemostats and opened.
o Wet gauze applied on subcutaneous tissue
o Bowels retracted
o Cecum identified and anterior taenia traced up to the base of appendix
o Appendix grasped with Babcock
o Mesoappendix serially clamped, cut and ligated.
o Base tied with Cotton 2-0
o Stump painted with Betadine
o Hemostasis
o Complete instrument and sponge count
o Close abdominal wall in layers
o Peritoneum with vicryl 0 continous interlocking
o Fascia with Vicryl 0 continous interlocking
o Skin with silk 4-0
o Dry sterile dressing

OPEN CHOLECYSTECTOMY
o Patient supine with padding at the posterior right upper quadrant
o Asepsis-antisepsis observed
o Sterile field prepared
o Oblique right subcostal incision, carried down to peritoneum
o Intraoperative findings noted
o Gallbladder is grasp with forceps at fundus
o Visceral peritoneum at the hepatoduodenal ligament opened
o Blunt dissection towards the cystic duct
o Cystic duct identified, traction suture applied to prevent passage of stone
o Dissection is continued along the same fold of visceral peritoneum upward
o Cystic artery identified and ligated
o Sharp dissection done to release the gallbladder from the liver bed from fundus down the cystic duct
o Cystic duct is ligated with silk 2-0 suture close to the common bile duct
o Irrigation with NSS
o Hemostasis done
o Complete count
o Layer by layer closure
o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0
o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0
o Skin closed subcuticularly using vicryl 4-0.
o Dry oSterile Dressing

CHOLECYSTECTOMY, IOC, CBD EXPLORATION,T-TUBE CHOLEDOCHOSTOMY

o Supine with padding at the posterior right upper quadrant
o Asepsis-antisepsis observed
o Sterile field prepared
o Oblique right subcostal incision, carried down to peritoneum
o Intraoperative assessment
o
o
CHOLECYSTECTOMY (same procedure):
o Perform transcystic intra-op cholangiogram
o Perform Kocher maneuver (release the lateral and posterior attachments of the 2nd portion of duodenum)
o Palpate the CBD, pancreas and duodenum
o Site of choledochotomy identified and skeletonized
o Traction suture placed laterally and medially using silk 4-0
o Vertical incision is made between the sutures
 o Irrigation with saline done proximally and distally to flush the stones out
o CBD stones removed using Randall forceps
o No.3 Bakes dilator is passed in the distal CBD and the tip is visualized thru the anterior wall of the duodenum
o T-tube is inserted with limbs cut short
o Choledochotomy is closed around the T-tube
o Saline is injected to T–tube to check for leaks
o Completion cholangiogram done to confirm the absence of stones
o Irrigation with NSS
o Hemostasis done
o Complete count
o T-tube is brought out thru a separate stab wound
o Layer by layer closure
o Peritoneum and post. rectus sheath - continuos interlocking -Vicryl-0
o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0
o Skin closed subcuticularly using vicryl 4-0.
o Dry Sterile Dressing

CHOLEDOCHODUODENOSTOMY
o Patient supine with padding at the posterior right upper quadrant
o Asepsis-antisepsis observed
o Sterile field prepared
o Oblique right subcostal incision (may extend to the left “chevron incision”) carried down to peritoneum
o Intraoperative findings noted
o
CHOLECYSTECTOMY (same procedure):
o Perform Kocher maneuver (release the lateral and posterior attachments of the 2nd portion of duodenum)
o Palpate the CBD, pancreas and duodenum
o Site of choledochotomy identified and skeletonized
o Traction suture placed laterally and medially using silk 4-0
o Vertical incision is made between the sutures
o CBD Exploration
o Mobilize the CBD and duodenum adequately
o Anchor the duodenum to the CBD by placing a row of silk 4-0 sutures posteriorly
o Make a transverse incision to the duodenum near to the CBD incision
o Side to side anastomosis in a single layer using interrupted silk 4-0
o Check for anastomtic leak
o Irrigation with NSS
o Hemostasis done
o Complete count
o Place a drain
o Layer by layer closure
o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0
o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0
o Subcutaneous closed by inverted T sutures using Chromic 2-0
o Dry Sterile Dressing

CHOLECYSTOJEJUNOSTOMY
o Supine with padding at the posterior right upper quadrant
o Asepsis-antisepsis observed
o Sterile field prepared
o Oblique right subcostal incision(may extend to the left “chevron incision”) or midline incision carried down to
peritoneum
o Intraoperative findings noted
 o Open the gallbladder transversely and assess the patency of the cystic duct, remove any stone
o Identify the jejunal site for anastomosis about 30 cms from the ligament of Treitz
o Anchor the jejunum to the fundus of gallbladder
o Make a transverse incision on the jejunum
o Perform the anastomosis in a single layer using interrupted silk 4-0 sutures
o Check for anastomtic leak
o Irrigation with NSS
o Hemostasis done
o Complete count
o Insert a drain
o Layer by layer closure
o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0
o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0
o Skin closed subcuticularly using vicryl 4-0.
o Dry Sterile Dressing

SPHINCTEROTOMY / SPHINCTEROPLASTY
o Patient supine with padding at the posterior right upper quadrant
o Asepsis-atnisepsis technique observed
o Sterile field prepared
o Oblique right subcostal incision(may extend to the left “chevron incision”) carried down to peritoneum
o Intraoperative assessment

o
CHOLECYSTECTOMY (same procedure)
o Perform IOC
o Perform Kocher maneuver (release the lateral and posterior attachments of the 2nd portion of duodenum)
o Palpate the CBD, pancreas and duodenum
o Carry out choledochotomy.CBDE
o Identify the duodenotomy site by passing bakes dilator into the CBD down as guide to the location of
the ampulla.
o Place stay sutures of silk 4-0 at the duodenotomy site
o Perform duodenotomy - vertical incision at the anti-mesenteric side
o Locate the ampulla
o At the 3 and 9 o’ clock positions in the periampullary area, place 5-0 silk stay sutures
o Perform 5 mm sphincterotomy between the 10 and 11 o’ clock positions using scalpel blade or a pott’s
scissor
o Suture the ductal and duodenal mucosa with interrupted 5-0 synthetic absorbable sutures
o Protect the pancreatic duct opening
o Hemostasis
o Close the duodenum in 2 layers using silk 0
o Close the CBD over a T-tube
o Place a drain
o Layer by layer closure
o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0
o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0
o Skin closed subcuticularly using vicryl 4-0.
o Dry Sterile Dressing

DISTAL PANCREATECTOMY
o Patient supine
o Asepsis-antisepsis technique observed
o Sterile drapes placed
o Midline incision or oblique left subcostal incision extended to the right and carried down to peritoneum
 o Palpate the entire abdomen
o Open the entire lesser sac by releasing the gastrocolic ligament
o Retract the stomach upward, and the transverse colon downward
o Assess the entire pancreas
o Assess the extent of the resection
o Release the tail from the spleen and develop a plane in between
o Mobilize the pancreas by incising the peritoneum on the superior border, protect the splenic artery
o Mobilize the inferior border of pancreas extending posteriorly
o Identify the site of resection
o Transect the pancreas
o Identify the pancreatic duct and close with mattress suture.
o Close the cut edge with interrupted sutures silk 3-0
o Irrigation with NSS
o Hemostasis done
o Complete count
o Insert a drain (close suction drain)
o Layer by layer closure
o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0
o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0
o Subcutaneous closed by Inverted T sutures using Chromic 2-0
o Skin closed subcuticularly using vicryl 4-0.
o Dry Sterile Dressing

WHIPPLE’S PROCEDURE
o o Patient supine
o o Asepsiis-antisepsis
o o Sterile drapes placed
o o Midline incision carried down from skin to peritoneum
o o Intaoperative findings noted
o o Resectability assessed
o o Dissection of portal vein and superior mesenteric vein
o o Extensive Kocher maneuver done from foramen of Winslow superiorly up to as far as the point where
SMV crosses the transverse (3rd portion) duodenum
o o Hepatic artery identified and skeletonized
o o distal CBD exposed
o o gastroduodenal artery identified and ligated
o o right gastric artery identified and ligated
o o cholecystectomy done
o o Distal CBD transected near duodenum
o o Gastric dissection
o o Left gastric artery identified and ligated
o o Ligate the gastroepiploic arcade along greater curvature of stomach
o o Identify site of gastric transection
o o stomach transected
o o Division of Pancreas about 3 cms from left of SMV
o o Neck and the body of the pancreas freed from underlying splenic vein from above
o o Ligation of the superior and inferior pancreatic artery
o o Uncinate process divided with electrocautery, edges sutured using continuous interlocking technique
with silk 4-0
o o Dissection and Division of Proximal Jejunum
o o End-to-end pancreatico-jejunal anastomosis by invagination done with a feeding tube inserted into the
pancreatic duct and exit into the jejunum 30 cms away, along antimesenteric wall and brought out thru the
skin (2-layer technique)
 o o End to side hepaticojejunal anastomisis about 8 cms away from pancreatico-jejunal anastomisis (2
layer technique)
o o Gastrojejunostomy using a Roux en Y technique (2 layer)
o o Jejunojejunostomy (2 layer)
o o Tube jejunostomy inserted
o o Drains inserted over hepatico-J and pancreatico-J anastomosis
o o Peritoneal washing
o o Hemostasis
o o Complete count
o o Layer by layer closure

SPLENECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Intraoperative findings noted
o gastrocolic omentum opened
o splenic artery identified and ligated proximally
o spleen mobilized
o splenophrenic, splenorenal and splenocolic ligaments ligated
o short gastric vessels ligated
o hilum dissected
o Individual ligation of the splenic vessels done
o the tail of the pancreas protected
o spleen removed, small feeding vessels ligated
o Hemostasis
o Irrigation done
o Correct count
o Abdominal closure
o Fascia - continuous interlocking suture using Vicryl 0
o Skin – Silk 4-0
o Dry sterile dressing

PORTOCAVAL SHUNT
o Patient supine
o Asepsis-antisepsis observed
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Intraop findings noted
o Portal triad exposed
o Isolation and mobilization of the portal vein
o Mobilization of the inferior vena cava by reflecting the duodenum to the left (Kocher maneuver)
o IVC skeletonized
o A side to side anastomosis or end to side portocaval shunt performed
o Runnjing 4-0 vascular suture used for the anastomosis
o Divide the portal vein near the hepatic side (if end to side)
o Oversew the hepatic portal stump with 5-0 polypropylene
o Anastomose the portal vein to the inferior vena cava using 6-0 polypropylene continuous suture
o Hemostasis
o Irrigation done
o Correct count
o Abdominal closure
 o Fascia - continuous interlocking suture using Vicryl 0
o Skin – Silk 4-0
o Dry sterile dressing

SPLENORENAL SHUNT
o Patient supine
o Asepsis-antisepsis observed
o Sterile drapes placed
o Midline incision or bilateral subcostal approach carried down from skin to peritoneum
o Intraop evaluation made
o Mobilize the transverse colon down to the splenic flexure and proximal descending colon
o Retract the small bowel forward and to the right
o Divide the greater omentum between the greater curvature of the stomach and the transverse colon
o Preserve the short gastric vessels to the hilum of the spleen
o Incise the peritoneum in the inferior surface of the pancreas and upwardly retract the body of the
pancreas
o Splenic vein mobilized, small tributary veins ligated
o Retroperitoneal dissection, left renal vein isolated and mobilized from the inferior vena cava to the
hilum of the kidney
o
DISTAL SPLENORENAL SHUNT:
o the splenic vein divided at the junction with the superior mesenteric vein.
o the hepatic end of the splenic vein oversewn
o the distal end to side of the left renal vein anastomosed using continuous 6-0 polypropylene
o
PROXIMAL SPLENORENAL SHUNT:
o splenic vein divided near the hilum of the spleen
o the splenic end of the splenic vein oversewn
o Anastomosis of the proximal end to side of the left renal vein done using continuous 6-0 polypropylene
o Ligation of the left gastric (coronary) vein and the right gastroepiploic vein
o Hemostasis
o Irrigation done
o Correct count
o Abdominal closure
o Fascia - continuous interlocking suture using Vicryl 0
o Skin – Silk 4-0
o Dry sterile dressing

HEPATIC RESECTION (RIGHT LOBECTOMY)

o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Bilateral oblique subcostal incision (chevron) carried down to peritoneum
o Intraoperative evaluation
o the liver mobilized from the hepatic flexure
o ligamentum teres hepatis and falciform ligament divided
o the gastrohepatic omentum divided
o cholecystectomy done
o
RIGHT LOBECTOMY:
o Hepatoduodenal ligament incised longitudinally posterior to the bile duct
o Right hepatic artery doubly ligated with silk 1-0 and divided
o Lymphatic vessels around hepatic artery ligated
 o portal vein bifurcation exposed
o Right portal vein exposed from right of the hepatoduodenal ligament
o Right lobar portal vein branch freed from surrounding lymphoareolar tissue and ligated
o Multiple small short hepatic veins between inferior vena cava and segments 1, 6, and 7 are ligated
o main right hepatic vein exposed
o retrocaval ligament bridging segments 1 and 7 divided
o Main right hepatic vein is dissected from the inferior vena cava and liver
o right hepatic vein transected with running silk 1-0 suture
o Parenchyma transected on the line of vascular demarcation
o Smaller bile ducts & vessels ligated on the resected side of liver
o Middle hepatic vein ligated during the parenchymal resection
o Parenchyma of caudate process transected to expose the anterior surface of the inferior vena cava
o right lobe of liver removed
o Hemostasis and bile stasis
o Suction drain placed
o Layer by layer closure

INGUINAL HERNIORRHAPHY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Oblique inguinal incision parallel to the inguinal ligament
o Incision carried down to fascia
o Large veins ligated ( superficial epigastric )
o external oblique aponeurosis opened along its fibers down to the eternal ring
o ilioinguinal nerve identified and spared
o spermatic cord isolated and retracted with an umbilical tape
o sac located anterior to the spermatic cord
o hernial sac skeletonized, opened, and transected
o Proximal part is dissected up to the internal ring and laterally to the deep epigastric vessels
o Reduction of content
o High ligation of the proximal sac
o Distal part of the sac left open after hemostasis
o conjoined tendon sutured to the inguinal ligament (shelving edge) from pubis to internal ring
o Hemostasis
o Complete count
o Wound closure
o Closure of the external oblique aponeurosis with vicryl 2-0 continous interlocking
o Skin - subcuticular with vicryl 4-0
o Dry sterile dressing

HERNIOPLASTY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Oblique inguinal incision parallel to the inguinal ligament
o Incision carried down to fascia
o Large veins ligated ( superficial epigastric )
o external oblique aponeurosis opened along its fibers down to the eternal ring
o ilioinguinal nerve identified and spared
o spermatic cord isolated and retracted with umbilical tape
o Hernial sac located anterior to the spermatic cord
o Hernial sac skeletonized, opened, and transected
 o Proximal part dissected up to the internal ring and laterally to the deep epigastric vessels
o High ligation of the proximal sac
o Distal part of the sac left open after hemostasis
o Prolene mesh, placed under spermatic cord, 3-4 cm larger than the defect circumferentially
o Prolene mesh sutured with silk 2-0 with interrupted mattress around the perimeter, anterior rectus
sheath, rectus muscle, and transversalis fascia along medial aspect and to the inguinal ligament laterally
o Cut the mesh and snug cut edge to the spermatic cord
o Hemostasis
o Correct count
o Wound closure
o Close the external oblique aponeurosis with vicryl 2-0 continuous interlocking
o Skin - subcuticular with vicryl 4-0
o Dry sterile dressing

o
o
o
o
REPAIR OF UMBILICAL HERNIA
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Curved infraumbilical incision carried down to subcutaneous tissue
o The hernial sac identified and dissected towards the fascial defect
o entire circumference of the defect exposed
o hernial sac then opened, adhesions released intraperitoneally
o Reduction of hernial sac contents into the abdominal cavity
o hernial sac removed
o Primary closure of the fascia using Vicryl 0 continuous interlocking with interrupted silk 0
o Hemostasis
o Correct count
o Drain if needed
o Wound closure
o subcutaneous tissue - chromic 2-0 simple interrupted
o skin - silk 3-0 simple interrupted
o Dry sterile dressing

Billroth I
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Intaoperative findings noted
o Mobilize the distal stomach
o Ligation of arteries and veins of the greater curvature distal to the point of the gastric transection
o gastrocolic ligament incised and transverse colon retracted downward
o gastroepiploic vessels ligated
o dissection carried out to the gastroduodenal area , small feeding vessel ligated
o vessels of the lesser curvature ligated
o right gastric artery ligated
o dissection continued toward the left gastric artery
o Line of gastric transection identified
o Stomach transected over a clamp
 o Duodenum transected just below the pyloric ring
o Partial closure of the gastric opening at the lesser curvature (2 layers) using chromic 3-0 continuous as
first layer followed by 3-0 silk interrupted as 2nd layer
o Anastomosis of the gastric opening to the duodenum (2 layers) using chromic 3-0 continuous as first
layer followed by 3-0 silk interrupted as 2nd layer
o A 3 suture bites at the lesser curvature area placed ( anterior stomach, posterior stomach and
duodenum) using silk 3-0
o Anastomosis reinforced with omentum
o Hemostasis
o Irrigation done
o Correct count
o Abdominal closure
o Fascia - continuous interlocking suture using Vicryl 0
o Skin – Silk 4-0
o Dry sterile dressing

SUBTOTAL DISTAL GASTRECTOMY (Billroth II)

oo Patient supine
oo Asepsis-antisepsis
oo Sterile drapes placed
oo Midline incision carried down from skin to peritoneum
oo Intaoperative findings noted
oo Distal stomach mobilized
oo arteries and veins of the greater curvature distal to the point of the gastric transaction ligated
oo gastrocolic ligament incised and transverse colon retracted downward
oo gastroepiploic vessels ligated
oo dissection to the gastroduodenal area carried out , small feeding vessel ligated
oo vessels of the lesser curvature ligated
oo right gastric artery ligated
oo dissection continued toward the left gastric artery
oo Line of gastric transection identified
oo Stomach transected over a clamp
oo Duodenum transected just below the pyloric ring
oo specimen removed
oo Duodenal stump iclosed in two layers with chromic 3-0 and silk 3-0
oo Partial closure of the gastric opening at the lesser curvature side
oo Proximal jejunal loop brought up in an antecolic fashion
oo gastric opening anastomosed to the loop of jejunum (2 layers) using a running 3-0 chromic for the mucosa
and interrupted 3-0 silk seromuscular
oo Hemostasis
oo Irrigation done
oo Correct count
oo Abdominal closure
oo Fascia - continuous interlocking suture using Vicryl 0
oo Skin – Silk 4-0
oo Dry sterile dressing

TOTAL GASTRECTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Intaoperative evaluation for operability
 o gastroesophageal area released and abdominal esophagus mobilized
o greater omentum separated from the transverse colon
o upward dissection of the greater omentum continued
o right and left gastroepiploic vessels ligated
o short gastric vessels ligated
o lesser omentum opened and removed
o right and left gastric arteries ligated
o entire stomach mobilized from the gastroesophageal junction to the proximal portion of the duodenum
o duodenum divided
o Duodenal stump closed in two layers with chromic 3-0 and silk 3-0
o abdominal esophagus divided, stay sutures placed on each side of the esophagus
o stomach removed
o A roux en Y esophagojejunal anastomosis performed
o proximal jejunum divided about 15 cms from ligament of Treitz
o distal end to the esophageal stump elevated without tension
o end to side or end to end anastomosis with 2 layer sutures
o opening of the proximal jejunum anastomosed to the jejunal loop in two layers (end to side)
o Hemostasis
o Irrigation done
o Correct count
o Abdominal closure
o Fascia - continuous interlocking suture using Vicryl 0
o Skin – Silk 4-0
o Dry sterile dressing

VAGOTOMY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Intraoperative evaluation

TRUNCAL VAGOTOMY
o abdominal esophagus
o peritoneum incised at the gastroesophageal junction
o anterior esophagus skeletonized
o (Left) anterior vagus nerve identified & a segment of the nerve removed, proximal and distal ends
ligated
o (Right) posterior vagus nerve palpated and identified, segment of the nerve removed, the proximal and
distal ends ligated

PROXIMAL GASTRIC VAGOTOMY

o abdominal esophagus mobilized
o right and left vagus nerves identified
o nerves of Laterjet localized, hepatic and celiac divisions protected
o distal half of the lesser curvature mobilized
o Starting approximately 6 cm from the pylorus, the neurovascular elements were divided and ligated
between the inner curve and the nerve of Laterjet
o Dissection continued toward the incisura angularis
o Re-peritonealization of the lesser curve done
o Hemostasis
o Irrigation done
o Correct count
 o Abdominal closure
o Fascia - continuous interlocking suture using Vicryl 0
o Skin – Silk 4-0
o Dry sterile dressing

PYLOROPLASTY
o Patient supine
o Asepsis-antisepsis
o Sterile drapes placed
o Midline incision carried down from skin to peritoneum
o Intraoperative evaluation

HEINEKE-MIKULICZ technique
o Pyloric area identified
o longitudinal pyloroduodenal incision about 5cm in length
o Wound closed transversely in 2 layers using 3-0 absorbable suture and 3-0 silk

FINNEY technique
o Pyloric area mobilized down to the 2nd portions of the duodenum
o site for pyloroduodenal incision identified
o pyloric area of the stomach sutured to the 1st portion of the duodenum with interrupted lembert suture
using 3-0 silk,
o U shaped pyloroduodenal incision made including the distal pyloric antrum and the proximal 2nd
portion of the duodenum
o Gastroduodenal opening closed in 2 layers
o Hemostasis
o Irrigation done
o Correct count
o Abdominal closure
o Fascia - continuous interlocking suture using Vicryl 0
o Skin – Silk 4-0
o Dry sterile dressing

GASTROJEJUNOSTOMY
oo Patient supine
oo Asepsis-antisepsis
o Sterile
o drapes placed
o Midline
o incision carried down to peritoneum
o Ligament
o of Treitz identified and jejunum brought in an antecolonic fashion
o longitudinal
o scratch mark made on the antimesenteric border of jejunum, beginning at a point 12cm from
ligament of Treitz, about 5cm in length
o Lembert
o suture of 3-0 silk placed on seromuscular coats of stomach and jejunum for about 5 cm
o A 5cm
o incision placed on the antimesenteric border of jejunum and along greater curvature of stomach
o posterior
o mucosal layer approximated using 3-0 Vicryl, as a continuous locked suture, penetrating both mucosal
and seromuscular coats towards the anterior margin by continuous Connell-type suturing
o A 4-0
o seromuscular Lembert suture (2nd layer) placed
o Complete
o hemostasis and sponge count
o Abdominal
o wall closure
o Fascia
o by continuous suture using vicryl 0
o Skinoby simple interrupted suture using silk 4-0
o Dry odressing

BELOW THE KNEE AMPUTATION

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

ARTERIO-VENOUS FISTULA
o Patient supine under local anaesthesia
o Asepsis-antisepsis
o Sterile drapes placed
o Radial artery and cephalic vein mobilized sufficiently to bring them together without angulation or tension
o Each vessel branch or tributary ligated at least a millimeter away from the main vessel
o Vein incised longitudinally with a pointed blade
o Incision then extended 7-9 mm with tenotomy scissors
o Arteriotomy then made similarly
o Continuous 7-0 suture used to crate a side-to-side anastomosis
o Back wall sutured first from within the vessels
o Upon completion of anastomosis, knot at midpoint anteriorly
o Thrill palpated
o Wound closed with subcuticular sutures

Exploratory Laparotomy
 Patient supine
 Induction of spinal anesthesia
 Asepsis/antisepsis
 Drapings done
 Vertical midline infraumbilical incision
 Peritoneum open with reference clamps
 Intraop findings: (size, type, location, etc.)
 *omental biopsy taken
 NSS lavage
 Abdominal incision closed in 2 layers
 Fascia closed using vicryl
 Skin closed with metal staples*
 Betadine paint applied
 Dressing done
 End of procedure

Primary repair of Abdominal Incisional Hernia

 Patient supine
 Asepsis-antisepsis
 Sterile drapes placed
 Infraumbilical incision carried down to subcutaneous tissue
 The hernial sac identified and dissected towards the fascial defect
 Entire circumference of the defect exposed
 Hernial sac then opened, adhesions released intraperitoneally
 Reduction of hernial sac contents into the abdominal cavity
 Hernial sac removed
 Primary closure of the fascia using Vicryl 0 continuous interlocking with interrupted silk 0
 Hemostasis
 Correct count
 Drain if needed
 Wound closure
 Subcutaneous tissue - chromic 2-0 simple interrupted
 Skin - silk 3-0 simple interrupted
 Dry sterile dressing

CHIELOPLASTY
 Patient supine under general anesthesia
 Asepsis and antisepsis
 Sterile Drapings placed
 Local anesthesia given
 Lip landmarks are marked out with methylene blue
 Skin incisions are made with a 6300 Beaver blade.
 The incisions are scored first, and the cleft edge mucosal flaps are elevated.
 Rotation incision is made and carried across the base of the columella
 A small, triangular-shaped piece of tissue remains attached to the columella (Millard's "C" flap) one sutured to the
medial portion of the nasal sill.
 Along with the circumalar incision, an incision in the intercartilaginous area of the nasal vestibule down to the
piriform aperture frees the nasal ala to advance medially independently of the lip.
 Incision for the interdigitation of this flap medially just above the vermilion cutaneous junction is not made until
satisfactory approximateion of the major flaps.
 The lateral and medial lip segments are freed by sharp dissection from the underlying maxilla in a supraperiosteal
plane.
 Cleft edge mucosal flaps was excised when the alveolar ridge is intact and rotated upward and used to help with
closure of the alveolar cleft and anterior floor of the nose.
 The lateral mucosal flap was also rotated into the intercartilaginous incision in the nose to avoid a raw surface at
this point.
 The mucosal surface sutured using a 4-0 Vicryl that grasps the lip muscle back along the upper edge of the
advancement flap as well as along the depths of the back cut of the rotation incision
 The orbicularis muscles are then approximated with 4-0 Vicryl sutures.
 The skin was sutured with ethilon 6-0, beginning at the vermilion cutaneous junction and advancing toward the
mucosa
 Dressing done
 End of Procedure

Uranoplasty
 Patient supine under general inhalation anesthesia
 Asepsis and antisepsis
 Sterile drapings placed
  Dingman retractor placed, the cleft margins, adjacent hard palate, and retromolar areas are exposed and
infiltrated with 1% lidocaine and epinephrine 1:100.000.
 Incision made at cleft margins to expose 3 layered tissue, nasal muscular palate
 Mucoperiosteal flaps are then elevated from the hard palate using a Freer elevator
 The neurovascular bundle coming from the greater palatine foramen is identified and preserved.
 The vomer flap is kept continuous posteriorly with the nasal mucosa layer of the soft palate.
 Muscle fibers are dissected from the soft palate nasal mucosa for 1 to 1.5 cm. The medial edges of the soft
palate are sutured using vicryl 4-0
 Mucoperiosteum is tightly bound down to the maxillary palatine suture and must be freed up from the suture to
provide sufficient medial mobility of the flaps in most clefts.
 The palate is closed in three layers.
 This closure is performed with a simple suture with the knots placed on the nasal side.
 The mucoperiosteal flaps are sutured anteriorly
 Hemostasis
 Betadine paint applied
 Dressing done
 End of procedure

Z - Plasty
 Patient supine under IV sedation
 Asepsis and antisepsis
 Sterile Drapings placed
 Local anesthesia given
 Lip landmarks are marked out with methylene blue
 Skin incisions are made with a 6300 Beaver blade.
 The incisions are scored first, and the cleft edge mucosal flaps are elevated.
 Rotation incision is made and carried across the base of the columella
 Single inferiorly based triangular flap on the lateral side of the flap, which is inserted into an incision on the medial
side of the lower portion of the lip (Z-plasty yechnique)
 Along with the circumalar incision, an incision in the intercartilaginous area of the nasal vestibule down to the
piriform aperture frees the nasal ala to advance medially independently of the lip.
 The lateral and medial lip segments are freed by sharp dissection from the underlying maxilla in a supraperiosteal
plane.
 Cleft edge mucosal flaps rotated upward
 The mucosal surface sutured using a 4-0 Vicryl that grasps the lip muscle back along the upper edge of the
advancement flap as well as along the depths of the back cut of the rotation incision
 The skin was sutured with ethilon 6-0, beginning at the vermilion cutaneous junction and advancing toward the
mucosa
 Dressing done
 End of Procedure