1 chapter 23 general surgery. 2 elsevier items and derived items © 2010, 2007 by saunders, an...

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Chapter 23Chapter 23

General SurgeryGeneral Surgery

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General Surgery

Important terms and definitions Review terms and definitions listed at beginning

of chapter Use your medical dictionary if necessary

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Abdominal surgery Abdominal wall Gastrointestinal Biliary – Gall bladder Spleen Pancreas Hepatic Breast (noncosmetic)

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(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Churchill Livingstone, Edinburgh, 2007, Elsevier.)

General Surgery

Four quadrants of the abdomen.

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(From Drake R, Vogel W, and Mitchell A: Gray’s Anatomy for Students, Edinburgh, 2004, Churchill Livingstone.)

Tissue layers of the abdominal wall and muscles of the abdomen.

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Abdominal incisions Midline Paramedian Subcostal Flank Inguinal McBurney's

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Abdominal incisions.

(Modified from Rothrock JC: Alexander’s care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)

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Inguinal region Hesselbach’s triangle Inguinal canal

• Spermatic fascia

• Cremaster muscle

• Genitofemoral nerve

• Ductus deferens

• Lymph vessels

• Testicular vein and artery

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Types of hernias Inguinal (direct or indirect hernia) Femoral hernia Incisional or ventral hernia Umbilical hernia Spigelian hernia

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Common inguinal hernias Strangulated Obstructed

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General Surgery

Open Repair of Indirect Inguinal Hernia

(Colorized from Moody FG: Atlas of ambulatory surgery, St Louis, 1999, Mosby.)

Incising aponeurosis of external oblique muscle.

Blunt dissection of the hernia sac from the spermatic cord.

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General Surgery

Open Repair of Indirect Inguinal Hernia

(Colorized from Moody FG: Atlas of ambulatory surgery, St Louis, 1999, Mosby.)

Placing the purse-string suture at the neck of the hernia sac.

Opening the hernia sac.

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General Surgery

Open Inguinal Hernia with Patch Graft

Suturing the mesh graft.(Colorized from Moody FG: Atlas of ambulatory surgery, St Louis, 1999, Mosby.)

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Transabdominal Extraperitoneal (TEP) Inguinal Hernia Repair.

A balloon expander inserted into the incision and inflated with air or normal saline.

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General Surgery

Femoral hernia Surgical goal

• An open repair of a femoral hernia is performed to restore strength to the inguinal floor and prevent abdominal tissue from protruding into the inguinal canal

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Incisional or ventral hernia To remodel a previous abdominal wall scar and

provide sufficient strength to prevent a recurring hernia

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Umbilical hernia repair Completed to repair weakening of abdominal wall

around or under umbilicus

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General Surgery

Spigelian hernia repair Completed to reduce protrusion of abdominal

viscera in “Spigelian zone”

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Introduction to gastrointestinal surgery Anatomy

• Esophagus

• Stomach

• Small intestine

• Large intestine (colon)

• Rectum and anus

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Anatomy of the stomach.

(Colorized from Rothrock JC: Alexander's care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)

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Anatomy of the small intestine.

(Colorized from Rothrock JC: Alexander's care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)

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Anatomy of the large intestine.

(Modified from Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.)

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(Modified from Applegate EJ: The anatomy and physiology learning system, ed 2, Philadelphia, 2000, Saunders.)

Rectum and anus.

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Bowel technique Separate area on Mayo or basin for instruments

used while the bowel is open Upon closure of the bowel, contaminated

instruments are removed from the field Before abdominal closure, gown (per facility

policy) and gloves are changed

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Special procedures Esophagogastroscopy Duodenoscopy Colonoscopy Sigmoidoscopy

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Esophagogastroscopy Endoscopic inspection of esophagus and stomach

Duodenoscopy Endoscopic inspection of duodenum

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Colonoscopy Endoscopic inspection of colon

Sigmoidoscopy Performed to examine tissue or obtain biopsy

specimen

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General Surgery

Laparotomy Open surgery of the abdominal cavity

• Confirm a diagnosis

• Exploratory

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Excision of esophageal diverticulum Removal of a portion of the esophagus, followed

by a straightening to prevent recurrence

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Laparoscopic Nissen fundoplication Commonly performed to treat gastroesophageal

reflux disease (GERD)

View of gastroesophageal (GE) junction with a portion of the stomach protruding through the hiatus. (From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

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Laparoscopic Nissen Fundoplication (cont.)

Dissection of the crura to expose the hiatus.

(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

Sutures are placed through the crura to close the defect.

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General Surgery

Laparoscopic Nissen Fundoplication (cont.)

Fundoplication or wrap of stomach around distal esophagus. An esophageal catheter (bougie) has been inserted.(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

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Vagotomy Performed to decrease gastric juices

• Procedure involves selective occlusion of vagus nerve

Traditionally used to treat peptic ulcer• Current knowledge has reduced number of operations

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General Surgery

Percutaneous endoscopic gastrostomy (PEG) Common method of providing nutrition via a

flexible tube inserted through the abdominal wall

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General Surgery

Partial gastrectomy Billroth I & II.

(From Economou SG, Economou TS: Atlas of surgical technique, ed 2, Philadelphia, 1996, Saunders.)

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Gastroduodenal anastomosis.

(From Economou SG, Economou TS: Atlas of surgical technique, ed 2, Philadelphia, 1996, Saunders.)

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Laparoscopic adjustable banded gastroplasty Reduces nutrient absorption to deal with morbid

obesity Two effective procedures are

• Vertical gastric banding

• Roux–en–Y gastric bypass

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Banded Gastroplasty

The visceral peritoneum is divided at the antrum of the stomach (angle of His).(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

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Banded Gastroplasty

(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

Tunneling instrument is placed behind the stomach.

Inflatable band is inserted through the tunnel.

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Banded Gastroplasty

Band is locked in place.(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

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Roux-en-Y Gastric Bypass

A, Division of the jejunum with surgical stapler B, Placing the stapler to perform side to side anastomosis. C, Creation of the gastric pouch.(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

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General Surgery

Transhiatal esophagectomy Performed for adenocarcinoma and squamous

cell carcinoma

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General Surgery

Transhiatal esophagectomy Performed through combined cervical and upper

midline incisions The esophagus is mobilized to the hiatus through

the cervical incision, and the stomach is mobilized through the abdominal incision.

The stomach is brought upward, and an anastomosis is formed with the proximal esophagus.

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General Surgery

Segmental resection of the small intestine Removal of a section of the small intestine with

an anastomosis to maintain continuity of the intestinal tract

Anastomosis• End-to-end

• Side-to-end

• Side-to-side

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End-to-End Anastomosis

The clamped intestinal stumps are aligned.

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End-to-End Anastomosis

The mucosa is sutured.

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End-to-End Anastomosis

The muscle and serosa layers are sutured.

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General Surgery

Removal of Meckel’s diverticula Surgical removal of the distal ileum

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Resection of the colon Removal of a section of the large intestine and

its continuity restored by anastomosis, or development of a colostomy (stoma)

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Colostomy

A, A disk of tissue is removed from the body wall. B, The intestinal stump is brought through the opening in the skin.C, The bowel may be sutured on the internal side.D, The bowel is everted and sutured to the skin.E, Healed stoma. A-D Colorized from Bauer JJ: Colorectal surgery illustrated, St. Louis, 1993 Mosby. E from Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Churchill Livingstone, Edinburgh, 2007, Elsevier.

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General Surgery

Partial colectomy Performed to remove a section of diseased colon

and restore continuity to the intestine

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General Surgery

Ileotransverse colostomy Surgical removal of a portion of the ileum and

transverse colon and a side-to-side anastomosis of the ileum and colon

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Right hemicolectomy Removal of diseased portion of right colon Bowel continuity reestablished by anastomosis

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Abdominoperineal resection of the rectum (APR) Performed to treat cancer of the rectum Necessitates formation of permanent colostomy

in abdominal wall

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Abdominoperineal resection.

B, The transverse anastomosis (TIA) stapler is used to close the rectal stump following resection of the abdominal colon. C, The gastrointestinal anastomosis (GIA) is used form an anal pouch using the ileum. The end-to-end anastomosis (EEA) is used to bring the stapled ileal pouch into position. It can then be hand sutured in place. (From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

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Appendectomy Removed when acutely infected Sometimes removed as prophylactic procedure

(incidental appendectomy) Can be done as open procedure or laparoscopic

procedure

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Open appendectomy Used when perforation has occurred

A, The appendix is divided from the cecum after ligation. B, A purse-string suture is placed around the stump. C, The stump is buried, and the purse string suture closed. (From Ortega JM Ricardo AE: Surgery of the appendix and colon. In Moody FG: Atlas of ambulatory surgery, Philadelphia, 1999, WB Saunders.)

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Laparoscopic appendectomy More common than open appendectomy

D, Laparoscopic appendectomy: The appendix is amputated using the GIA stapler. E, The mesoappendix is divided. F, The appendix is brought out of the abdomen through one of the operative ports.(From Moody FG: Atlas of ambulatory surgery, Philadelphia, 1999, WB Saunders.)

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Hemorrhoidectomy Hemorrhoids are classified as

• Internal (inside the rectum)

• External (outside the rectum)

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Excision of pilonidal cyst Epithelial tissue trapped below skin’s surface in

area of sacrum and coccyx Cyst is removed when it causes recurrent infection Sinus tract often present

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Excision of Anal Fistula

Anal fistula involving the sphincter. (From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Edinburgh, 2007, Churchill Livingstone Elsevier.)

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Surgery of the biliary system, the liver, the pancreas, and the spleen

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Locations of the liver, the gallbladder, and the pancreas.

(Modified from Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.)

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Biliary system.

(From Drake R, Vogl W, Mitchell A: Gray’s Anatomy for Students, Edinburgh, 2004, Churchill Livingstone).

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Anatomical relationship of the spleen and the arterial system.

(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5 Edinburgh, 2007, Churchill Livingstone Elsevier.)

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Endoscopic retrograde cholangiopancreatography (ERCP) Select patients may benefit from this procedure

before biliary, hepatic, and pancreatic surgeries

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General Surgery

Laparoscopic cholecystectomy Complete surgical removal of gallbladder Performed to prevent or treat inflammation or

obstruction Common diseases of biliary system

• Cholelithiasis – Presence of gallstones

• Cholecystitis – Inflammation of bladder

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Cholecystectomy (open) A cholecystectomy is the removal of a diseased

gallbladder

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Operative cholangiography Comprises imaging studies in which a contrast

medium is injected into the biliary ducts to detect gallstones or a stricture

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General Surgery

Splenectomy Removal of the spleen to stop hemorrhage caused

by trauma or to treat disease

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General Surgery

Pancreaticojejunostomy (Whipple procedure) A Whipple procedure is performed to treat

pancreatic cancer

(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5 Edinburgh, 2007, Churchill Livingstone Elsevier.)

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Endoscopic distal pancreatectomy Removal of portion of pancreas

• For palliative treatment of malignant tumor

• To remove benign lesion

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Surgical resection of the liver Wedge resection Segmental resection Lobectomy

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Segmental section Goal is removal of one or more defined liver

segments

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Liver transplantation One of most successful transplant procedures Potential recipients screened

• Is disease life threatening or reversible?

• Is disease correctable by transplant?

• Age of recipient?

• Previous abdominal surgery?

• Psychological and psychosocial considerations?

• Physical status?

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Breast surgery

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The breasts Are functional part of female reproductive system

• Provide milk for the infant

• Respond to hormonal changes

Can have effect on sexual identification and body image

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Anatomy of the breast.

(From Donegan WL, Spratt JS: Cancer of the breast, Philadelphia, 1988, WB Saunders.)

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Psychological considerations Surgery can produce anxiety and depression Respect and presence are critical components of

patient care Instruments and supplies

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Wire localization and breast biopsy A fine wire is inserted into the breast during

fluoroscopy This is a specific technique used to identify the site

of a suspected mass

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Breast-conserving surgery for a mass (lumpectomy, segmental mastectomy) A breast mass is removed to confirm a diagnosis

or to treat malignancy

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Breast-Conserving Surgery for a Mass (cont.)

Incisions for a skin-sparing biopsy.

(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

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Axillary dissection Axillary lymph nodes can include cancer cells from

a malignant tumor

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Total mastectomy with axillary lymph node dissection Goal is to remove breast and axillary lymph nodes In skin-sparing mastectomy, overlying skin tissue,

areola, and nipple are not removed