THYROIDECTOMYo Mobilization and dissectiono thyroid capsule dissected away from it on both sides.o sternohyoid & sternothyroid muscle retracted laterallyo cleavage plane created between the thyroid gland and the strap muscles,o cervical fascia incised in the midline,o Lower flap created by subplatysmal dissection up to suprasternal notch in the midlineo Upper flap created by subplatysmal dissection up to the notch of the thyroid cartilagein the midline of the dissectiono transverse curved incision on skin crease or 2 cm above sternal notch, carried down tothe platysmao Sterile drapes placedo Asepsis-antisepsiso Patient supine with neck hyperextendedWOUND CLOSURE:o light dressingo subcuticular suturing of skin with vicryl 4-0o platysma muscles apposed, dermis apposed,o strap muscles apposed at midline, chromic 2-0PARTIAL (subtotal) THYROIDECTOMYo Correct counto Drain (rational placement)o Lavage or irrigationo Hemostasiso segment approximated to the tracheao suture ligation of the thyroid parenchyma and surface veins.o gland transectedo multiple hemostats applied at the thyroid parenchymaTOTAL LOBECTOMYo Hemostasiso pyramidal lobe removed when presento lobe and isthmus dissected from the tachea, and removeo inferior thyroid artery ligated

o parathyroids identified and sparedo recurrent laryngeal nerve identified and sparedo superior thyroid artery and vein ligated close to the gland to avoid ligation of superiorlaryngeal nerve.o middle thyroid vein ligatedo Lobe retracted medially and anteriorly using one hand while dissecting posteriorly(close to the gland)PAROTIDECTOMYo LOWER FLAP: dissection of the skin downward and posteriorly toward the mastoidprocesso UPPER FLAP: traction provided upward and medially on the dissected skin, and laterallytoward the external auditory canal.o FLAP formation:o skin and fat elevated using scalpel, sharp and blunt dissection upward, medially,laterally, downward, and posteriorly.o deep incision made into the superficial cervical fasciao (anteriorly: fat and platysma ; posteriorly: fat only)o Modified Y incision making a vertical pre- ando postauricular incisions united approximately at the angle of the mandible, forming a Ywhich converge with a transverse incision 3 cm below the mandibleo STERILE DRAPES PLACEDo the lateral angle of the eye and labial commisure uncoveredo ASEPSIS/ANTISEPSIS doneo Patient supine, head turned to the contralateral side with neck hyperextendedo may sacrifice the great auricular nerve and the posterior facial vein, which are both veryclosely situated in the vicinity of the lower flap and the lower parotid borderFACIAL NERVE IDENTIFICATION:

o main trunk of the facial nerve exposed at a depth of about 1.5 cm. from the externalsurface of the mastoid process by dissecting directly downward along the anteriorborder of the mastoid process above the attachment of the posterior belly of thedigastric muscle.o hemostat inserted between the mastoid and the glando parotid fascia incised carefully & the superficial lobe of the parotid mobilizedo distal phalanx of the left index finger placed on themastoid, pointing to the eye of thepatientRESECTION OF THE SUPERFICIAL LOBERESECTION OF THE DEEP LOBEo duct then ligated and dividedo the superficial lobe totally mobilized and resected Stensen’s duct encountered as thedissection carried toward the ends of the branches of the facial nerveo further anterior nerve dissection toward the periphery of the gland,o with gentle traction of the glando deep lobe removed carefully, working under theo Hemostasiso facial nerve by the piecemeal dissection technique.o Complete removal of the parotid gland reveals the ff structures: (acronym VANS)o vein: internal jugularo arteries: external and internal carotido nerves: IX, X, XI, XIIo anatomic entities starting with “S”:styloid process; muscles: styloglossus,stylopharyngeus, stylohyoido LIGHT DRESSINGo subcuticular suturing of skin with absorbable sutureo dermis apposed,o WOUND CLOSURE: platysma muscles apposed,

o CORRECT COUNTo DRAIN (rational placement)o LAVAGE or IRRIGATIONo the contralateral sideo Light dressingo Continuous 4-0 vicryl for the approximation of the platysma muscle and subcuticularsuture for the skino A two-layer closureo Placement of suction drainso Thorough irrigation with salineo Completion of the dissectiono Transection & ligation of facial veino Tail of parotid transected along with the attachments of sternocleidomastoid muscleo External maxillary artery ligated and transectedo A fine silk suture ligature then placed distally. Distal to the suture ligature free tiesecured, and the vessel cut between the two distal ligatureso Internal jugular vein clamped at this point and tied with 2-0 silk passed about the vesselo The muscle and lymph node mass reflected upward to the point at which the internaljugular vein immobileo Posterior belly of the digastric and stylohyoid muscles removed with the contents of thedissectiono hyoglossus muscle from deep plane of dissection, while the digastric and stylohyoidmuscles form the inferior planeo Ligation & division of Wharton duct and tributaries of the lingual veino Preservation of hypoglossal nerve and the accompanying veinso Division of lingual nerve and the submandibular gland ducto Dissection of submandibular prevascular and retrovascular lymph nodes into thespecimen area

o Exposure & transection of the facial vesselso Exposure & preservation of ramus mandibulariso Dissection of the Submandibular Triangleo Dissection of internal jugular veino Preservation of the branches of the cervical plexuso Spinal accessory nerve and the transverse cervical vessels dividedo Removal of all the contents of the posterior triangleo Fibrofatty tissue of the posterior triangle of the neck dissected forward and downwardin a plane immediately lateral to the fascia of the splenius and the levator scapulaemuscleso Identification and preservation of strap muscleso The nodes, fat, and fascia reflected downward over the anterior belly of the digastric mmuscleo Dissection of submental triangle, crossing the midline to the opposite anterior belly ofthe digastric muscleo External maxillary artery and anterior facial vein transected at the mandibular edge.Including in the dissection the pre- and retrovascular lymph nodeso Spinal accessory nerve transected and with associated lymph nodes reflected upwardo Preservation of phrenic nerveo Superior belly of the omohyoid muscle detached from the hyoid boneo Inferior belly of omohyoid transectedo Dissection carried upward following the plane formed by the anterior edge of thesuperior belly of the omohyoid muscleo Suture-ligation with 1-0 silk then division of internal jugular vein in between ligatures

o Dissection of internal jugular vein off the internal carotid artery and vagus nerveo Ansa hypoglossi is transectedo Carotid sheath openedo Sternocleidomastoid muscle reflected upward, using blunt and sharp dissectiono Ligation of external juguIar with distal suture ligature and a proximal tie, thentransectedo Transection of sternocleidomastoid muscleo Subclavian vein, the thoracic duct on the left side and the accessory duct on the rightside preservedo posterior edge of the sternocleidomastoid muscle openedo Space anterior to the sternocleidomastoid muscle opened, exposing the carotid sheatho 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 hyoidboneo Superior flap createdo Skin incision created from the inferior border of mastoid going down alongsternocleidomastoid muscle and curved as a low collar curvilinear insicionMODIFIED RADICAL MASTECTOMYo Incision chosen that would have the least tension on closure, either elliptical, verticalo Using a sterile marking pen, circle drawn 2-3 cm away from the perimeter of theprimary tumor. In addition to the area of skin outlined by the circle drawn around thetumor include the entire areola and nipple in the patch of skin left on the specimen.o Sterile drapes placedo Asepsis/ Antisepsis done

o Patient positioned with ipsilateral arm abducted in 90º on an arm board and place afolded sheet, about 5 cm thick under the patients scapula and posterior hemithoraxetc.o Dry sterile dressingo 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 withinterrupted 3-0 vicryl and close the skin with vicryl 4-0 subcuticularlyo Complete counto Irrigationo Hemostasiso Five nerves should be identified and protected if possibleo long thoracic nerve- innervating the serratus anterior muscles, if injured caused wingeddeformityo thoracodorsal nerve- innervates the latissimus dorsi muscleo medial anterior thoracic-lateral to the pectoralis minor muscleo lateral anterior thoracic-medial edge of the pectoralis minoro subscapularo Using a scalpel or metzenbaum scissors, axillary contents of fat and lymph nodesevacuated, pushing them towards the breast in continuityo Brachial plexus and axillary artery protectedo Axillary vein and its tributaries identified. Ligation of all the tributaries toward thebreast with 3-0 or 4-0 silk.o The clavipectoral fascia opened, for access to the axilla. Pectoralis major and minorprotected.o Arterial perforators entering the breast ligated with vicryl 2-0o Dissection of the breast began medially. Pectoralis fascia elevated

o Use electrocautery for the formation of the upper and lower flapso Hemostasis obtained by applying electrocoagulation to each bleeding pointo Incision made through all the layers of the skinTOTAL MASTECTOMYo Same as modified radical mastectomy without the axillary dissectionWIDE EXCISION WITH AXILLARY DISSECTIONo Wound closureo Complete counto Hemostasiso Axillary cavity drained with Jackson pratto Dissection completed and specimen separated from the axillary vein.o Thoracodorsal nerve protected, identified closed to the ant margin of the latissimusdorsi muscle and the long thoracic nerve, under the fascia of the serratus anteriormuscle.o Axillary vein identified at the medial area of the pectoralis minor and tributaries ligated.o Both pectoralis muscles retracted.o Transverse incision at the lower axilla.o cosmetic incision elliptical incision. Remove the tumor and healthy mammary tissue andsend it to lab for frozen sectiono Sterile drapes placedo Asepsis-antisepsiso Patient supineEXCISION OF BRANCHIAL CLEFT CYSTo WOUND CLOSUREo CORRECT COUNTo LAVAGE or IRRIGATIONo HEMOSTASISo dissection of the cyst or sinus cephalad toward the pharyngeal wallo carotid sheat and hypoglossal nerve visualizedo sternocleidomastoid muscles separated and elevated, always using the medial bordero Multiple incisions if the cyst or sinus is low

o A small transverse incision done above the cyst; around a sinus an elliptical incisionmade.o Sterile drapes placedo Asepsis-antisepsiso Patient supine, head turned to the contralateral side with neck hyperextendedEXCISION OF THE THYROGLOSSAL DUCT CYSTo HEMOSTASISo Foramen cecum excised in continuity and the defect closed with figure-of-eight 4-0chromic catgut or any other absorbable suture.o The foramen cecum also requires special attention. The anesthesiologist’s index finger isinserted into the patient’s mouth, elevating the foramen cecum. With continouscephalad dissection, one reaches the foramen cecum by palpating the finger of theanesthesiologist just under the thyrohyoid membrane.o Thyrohyoid membrane now exposedo Upward dissection continued bilaterally to the midline where the tract is locatedo Curved hemostat inserted under the central part of the hyoid bone. With heavy scissorsor small bone cutter, bone cut on both sides.o Some cuffs of sternohyoid and mylohyoid left attached to the bone, as well as somecuffs of the underlying geniohyoid and genioglossus attached to the cephalad tract.o Central part of the hyoid bone cleaned.o Special care taken of the hyoid bone and tract.o Cyst dissected and isolated with a small hemostat and scissor. The involved anatomicalentities depend upon the location of the cyst: suprahyoid (rare), hyoid (common),

infrahyoid or suprasternal (rare).o Lower flap elevated almost to the isthmus of the thyroid glando Formation of the flaps: the upward elevation reaching the hyoid bone and extendingcephalad 1-2 cm.o superficial fascia (fat and platysma) incisedo transverse incision over the cyst.o Sterile drapes placedo Asepsis-antisepsiso Patient supine with neck hyperextendedo WOUND CLOSUREo Reconstruction. Midline approximation performed of the mylohyoid and sternohyoidwith interrupted sutureso CORRECT COUNTo LAVAGE or IRRIGATIONEXCISION OF CYSTIC HYGROMAo WOUND CLOSUREo CORRECT COUNTo DRAIN (rational placement)o LAVAGE or IRRIGATIONo HEMOSTASISo Extensions into various tissue planes and between muscle and nerve bundles, followed,exposed and removed to effect a complete cureo Careful sharp dissection, usually employing a no. 15 blade supplemented with bluntdissectiono Sharp and blunt dissection upward, and downwardo Skin and fat carefully elevated using a knifeo Adequate transverse incision above the cysto Patient supine, head turned to the contralateral sideTRACHEOSTOMYo Iodoform packed in the subcutaneous tissue around the tracheostomy tubeo The tube secured with umbilical tape around the patient’s neck.o correct count

o Hemostasiso Hardy-shiley tracheostomy tube inserted as the endotracheal tube is slowly backed outo tracheal opening widened with a tracheal spreadero cricoid cartilage and 1st tracheal ring prtected to avoid postoperative tracheal stenosiso vertical incision through the 2-3 tracheal ring.o anterior tracheal wall mobilized and elevated using a hook at the lower border of thecricoid cartilageo anterior wall of the trachea below the isthmus cleanedo thyroid isthmus and thyroidea ima identified & ligatedo extended to expose the full length of the strap muscleso incision through the cervical fascia in the midline,o adult: vertical or transverse incisiono children: vertical incision to avoid injury of the arteries and veins locatedunder the anterior border of SCMo Incision two finger breadths above the sternal notcho Asepsis-antisepsiso Patient supine with neck hyperextendedRIGHT HEMICOLECTOMYo Patient supineo Asepsis-antisepsiso Sterile drapes placedo Midline incision carried down from skin to peritoneumo Exploration of the entire peritoneal cavityo Mobilization of the right colon by incision of the right paracolic peritonealreflection from distal ileumo down to the transeverse colon.o Renocolic and hepatocolic ligaments dividedo Duodenum protectedo gonadal vessels separated and right ureter identified

o Lines of resection identifiedo Terminal ileum and transverse colon occluded with umbilical tape.o ileocolic pedicle ligated.o right branch of middle colic pedicle ligatedo distal ileum and transverse colon divided just after the hepatic flexureo viability of the cut segments checkedo Bowel edges painted with betadineo Resection of the mesentery down to the rooto Two- layer end to end anastomosis (ileocolic) using an interrupted silk 4-0(Connel technique) and interrupted silk 4-0 (Lembert technique) for theseromuscular layero Anastomosis checked for leakageo mesenteric decfect clsoed with Chromic 2-0o Hemostasiso Peritoneal washingo Complete counto Closure layer by layero Peritoneum and fascia – Vicryl 0 continuous interlocking sutureo Skin – Silk 4-0LEFT HEMICOLECTOMYo Patient supineo Asepsis-antisepsiso Sterile drapes placedo Midline incision carried down from skin to peritoneumo Exploration of the entire peritoneal cavityo left colon from sigmoid to left transverse colon mobilized by incising theperitoneal reflection of the left paracolic gutter.o Splenocolic, renococolic and pancreaticocolic ligaments dividedo Gonadal vessels separated and left ureter identifiedo Distal transverse colon and sigmoid colon occluded with umbilical tapeo Ligation the inferior mesenteric artery at its take off from the aorta andthe inferior mesenteric vein

o Lines of resection identifiedo proximal sigmoid divided followed by the left transverse colon justbefore the splenic flexureo viability of the cut segments checkedo Bowel edges painted with betadineo Resection of the mesentery down to the rooto Two- layer end to end anastomosis using an interrupted silk 4-0 (Conneltechnique) and interrupted silk 4-0 (Lembert technique) for theseromuscular layero Anastomosis checked for leakageo Mesenteric defect closed with chromic 3-0o Hemostasiso Peritoneal washingo Complete counto Closure layer by layero Peritoneum and fascia – Vicryl 0 continuous interlocking sutureo Skin – Silk 4-0TRANSVERSE COLECTOMYo Patient supineo Asepsis-antisepsiso Sterile drapes placedo Midline incision carried down from skin to peritoneumo Exploration of the entire peritoneal cavityo Gastrocolic ligament releasedfrom the hepatic to splenic flexureo Hepatic and splenic flexure releasedo Transverse colon occluded with umbilical tapeo Middle colic artery and vein ligatedo Lines of resection identifiedo Transverse colon divided at the hepatic and splenic flexureo Viability of the cut segments checkedo Bowel edges painted with betadineo Resection of the mesentery down to the rooto Two- layer end to end anastomosis using an interrupted silk 4-0 (Conneltechnique) and interrupted silk 4-0 (Lembert technique) for theseromuscular layer

o Anastomosis checked for leakageo Mesenteric decfect closedo Hemostasiso Peritoneal washingo Complete counto Closure layer by layero Peritoneum and fascia – Vicryl 0 continuous interlocking sutureo Skin – Silk 4-0SIGMOID COLECTOMYo Patient supineo Asepsis-antisepsiso Sterile drapes placedo Low midline incision carried down from skin to peritoneumo Exploration of the entire peritoneal cavityo Left colon carefully mobilized from rectosigmoid to descending colon byincising the peritoneal reflection of the paracolic guttero Splenocolic and renocolic ligaments dividedo Gonadal vessels separated and left ureter identifiedo Sigmoid colon occluded with umbilical tapeo Incision made at the right side of the sigmoid mesocolon down to thedistal sigmoido Inferior mesenteric artery ligated just after take off from the aorta andthe inferior mesenteric veino Lines of resection identifiedo proximal sigmoid divided followed by the distal sigmoido Bowel edges painted with betadineo Check for the viability of the cut segmento Resection of the mesentery down to the rooto Two- layer end to end anastomosis using an interrupted silk 4-0 (Conneltechnique) and interrupted silk 4-0 (Lembert technique) for theseromuscular layero Anastomosis checked for leakageo Mesenteric decfect closedo Hemostasis

o Peritoneal washingo Complete counto Closure layer by layero Peritoneum and fascia – Vicryl 0 continuous interlocking sutureo Skin – Silk 4-0o Dry sterile dressingANTERIOR RESECTIONo Patient supineo Asepsis-antisepsiso Sterile drapes placedo Low midline incision carried down from skin to peritoneumo Exploration of the entire peritoneal cavityo Mobilization of the left colon from descending to rectosigmoid colon byincision of the peritoneal reflection of the left paracolic gutter down tothe sacral promontoryo gonadal vessels separated and left ureter identifiedo dissection continued to the rectovesical spaceo right ureter identified by an incision at the right side of the sigmoidmesocolon down to rectovesical poucho inferior mesenteric artery ligated just after take off from the aorta andthe inferior mesenteric veino Lines of resection identifiedo Divide the proximal sigmoid followed by the rectosigmoid segmento Bowel edges painted with betadineo viability of the cut segment checkedo Resection of the mesentery down to the rooto Two- layer end to end anastomosis using an interrupted silk 4-0 (1stlayer) and interrupted silk 4-0 (Lembert technique) for the seromuscularlayero Anastomosis checked for leakageo mesenteric defect closedo Hemostasiso Peritoneal washingo Complete counto Closure layer by layer

o Peritoneum and fascia – Vicryl 0 continuous interlocking sutureo Skin – Silk 4-0TOTAL COLECTOMYo Patient supineo Sterile field preparedo Midline incision carried down from skin to peritoneumo Exploration of the entire peritoneal cavityo Mobilization the right colon by incising the right paracolic peritonealreflection from distal ileum down to the transverse colon.o Right renocolic and hepatocolic ligaments dividedo Duodenum protectedo gonadal vessels separated and right ureter identifiedo Mobilization the left colon from sigmoid to left transverse colon byincising the peritoneal reflection of the left paracolic gutter.o Division of the splenocolic, renococolic and pancreaticocolic ligamentso gonadal vessels separated and left ureter identifiedo gastrocolic ligament releasedo hepatic and splenic flexure releasedo Ligation of the lymphovascular pedicles starting from the ileocolic, rightcolic, middle colic and inferior mesenteric vesselso Mesenteric dissectiono Mobilization of distal part downward to the sacral promontory and thepre-sacral areao Lines of resection identifiedo Distal ileum transected followed by transaction ofthe proximal rectumo Two- layer end to end anastomosis (ileorectal) using an interrupted silk 4-0 (1st layer) and interrupted silk 4-0 (Lembert technique) for theseromuscular layero Anastomosis checked for leakageo mesenteric defect closedo Hemostasiso Peritoneal washingo Complete count

o Closure layer by layero Peritoneum and fascia – Vicryl 0 continuous interlocking sutureo Skin – Silk 4-0TRANSVERSE/ SIGMOID LOOP COLOSTOMYo Patient supineo Asepsis-antisepsiso Sterile drapes placedo Transverse incision over right or left upper quadrant for transverse andleft lower quadrant for sigmoido Division of the anterior rectus sheatho rectus abdominis muscles retractedo posterior rectus sheath and peritoneum dividedo Exteriorization of transverse/sigmoid colon into the woundo exteriorized bowel sutured to the fascia with silk 4-0o small hole created at the mesenteric border of the colon and plastic rodinsertedo colon opened and matured to the skin with 4-0 vicryl sutureso Cover the colostomy with wet gauzeCLOSURE OF COLOSTOMYo Patient supineo Asepsis-antisepsiso Sterile field preparedo Colostomy occluded with gauzeo Elliptical incision around the colostomyo Mobilization of the colostomy from subcutaneous fat down to fascialattachmentso Peritoneal cavity openedo colon released from adhesions in the peritoneal cavityo colon debrided or resected if neededo Two- layer anastomosis using an interrupted silk 4-0 (1st layer) andinterrupted silk 4-0 (Lembert technique) for the seromuscular layero Anastomosis checked for leakageo Hemostasiso Complete counto Wound closureo Peritoneum and fascia – Vicryl 0 continuous interlocking suture

o Subcutaneous tissue and skin - openABDOMINOPERINEAL RESECTIONo Patient supine in the lithotomy positiono Anus is closed with silk 0 sutureo Sterile field preparedo Low midline incision carried down to peritoneumo Exploration of entire peritoneal cavityo Mobilization of the sigmoid & descending colon by incising the peritonealreflection of the left paracolic guttero Gonadal vessels separated and left ureter identifiedo Mobilization of distal part downward to the sacral promontory and thepre-sacral areao dissection to the rectovesical space continuedo incision made at the right side of the sigmoid mesocolon down torectovesical pouch and right ureter identifedo Proximal sgmoid occluded with umbilical tapeo Ligation of inferior mesenteric artery, just after take off from the aortaand the inferior mesenteric veino The lymphatic tissue in the pelvis removed with the specimeno Sharp and blunt dissection of the rectum up to the level of the tip of thecoccyxo Lateral stalks divided, and ligated with 2-0 silk sutureso Lines of resection identifiedo Sigmoid colon transected, both cut ends closed to prevent spillageo Colostomy site preparedPERINEAL DISSECTION:o Skin – Silk 4-0o Peritoneum and fascia – Vicryl 0 continuous interlocking sutureo Closure layer by layero Complete counto Peritoneal washingo peritoneum in the pelvic area closedo Hemostasiso Colostomy matured to the skin

o Skin closed with simple interrupted sutureso Perineum packed with gauze inside a gloveo Washing with NSSo Hemostasiso prostate gland / posterior vaginal wall can be included in the specimen ifnecessaryo Anterior part of the perineal dissection carried outo transected sigmoid specimen delivered through the perineal openingo levator muscles opened upward beginning from below up to the region of thepuborectalis slingo Inferior and middle hemorrhoidal vessels ligatedo Sharp division of Waldeyer’s fasciao anococcygeal ligament cut with cauteryo perirectal fat incised down to the levator diaphragmo Incision carried into perirectal fato Elliptical incision 3-4 cm anterior to the anal orifice and terminating at the tip of coccyxHEMORRHOIDECTOMYo Light dressingo Achieve complete hemostasiso hemorrhoidal pedicle oversewn with a running lock-stitch of chromic 2-0 until entiredefect has been closedo hemorrhoidal mass dissected and divided with electrocauteryo Hemorrhoid drawn away from the sphincter with blunt dissectiono Submucosal dissection of hemorrhoidal tissue down to the internal sphincter muscleo elliptical incision over anoderm including skin tag madeo Suture ligation of feeding vesselo hemorrhoids with hemorrhoidal clampo hemorrhoids identifiedo gauze sponge inserted into the lower rectum

o anal dilatation and anoscopic evaluation performedo Sterile field preparedo Patient in a lithotomy positionFISTULOTOMY/FISTULECTOMYo Dry sterile dressingo Hemostasiso All tracts kept fully openedo soft tissues overlying the tract divided and part of the margin excised toconvert the deep slit-like defect into a V-shaped defecto probe inserted into fistulous tract while anal canal palpated to identify the externalopeningo external openings of the fistula identifiedo anal dilatation and anoscopic evaluation performedo Sterile field preparedo Patient in a lithotomy positionAPPENDECTOMYo Dry sterile dressingo Skin with silk 4-0o Fascia with Vicryl 0 continous interlockingo Peritoneum with vicryl 0 continous interlockingo Close abdominal wall in layerso Complete instrument and sponge counto Hemostasiso Stump painted with Betadineo Base tied with Cotton 2-0o Mesoappendix serially clamped, cut and ligated.o Appendix grasped with Babcocko Cecum identified and anterior taenia traced up to the base of appendixo Bowels retractedo Wet gauze applied on subcutaneous tissueo Peritoneum grasp with hemostats and opened.o Muscle splitting doneo Fascia cut obliquelyo Transverse incision at the right lower quadrant carried down from skin up to

subcutaneous tissueo Sterile field preparedo Asepsis-antisepsiso Patient supineOPEN CHOLECYSTECTOMYo Sterile field preparedo Asepsis-antisepsis observedo Patient supine with padding at the posterior right upper quadranto Dry Sterile Dressingo Skin closed subcuticularly using vicryl 4-0.o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0o Layer by layer closureo Complete counto Hemostasis doneo Irrigation with NSSo Cystic duct is ligated with silk 2-0 suture close to the common bile ducto Sharp dissection done to release the gallbladder from the liver bed from fundus downthe cystic ducto Cystic artery identified and ligatedo Dissection is continued along the same fold of visceral peritoneum upwardo Cystic duct identified, traction suture applied to prevent passage of stoneo Blunt dissection towards the cystic ducto Visceral peritoneum at the hepatoduodenal ligament openedo Gallbladder is grasp with forceps at funduso Intraoperative findings notedo Oblique right subcostal incision, carried down to peritoneumCHOLECYSTECTOMY, IOC, CBD EXPLORATION,T-TUBE CHOLEDOCHOSTOMYo Dry Sterile Dressingo Skin closed subcuticularly using vicryl 4-0.o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0

o Peritoneum and post. rectus sheath - continuos interlocking -Vicryl-0o Layer by layer closureo T-tube is brought out thru a separate stab woundo Complete counto Hemostasis doneo Irrigation with NSSo Completion cholangiogram done to confirm the absence of stoneso Saline is injected to T–tube to check for leakso Choledochotomy is closed around the T-tubeo T-tube is inserted with limbs cut shorto No.3 Bakes dilator is passed in the distal CBD and the tip is visualized thru the anteriorwall of the duodenumo CBD stones removed using Randall forcepso Irrigation with saline done proximally and distally to flush the stones outo Vertical incision is made between the sutureso Traction suture placed laterally and medially using silk 4-0o Site of choledochotomy identified and skeletonizedo Palpate the CBD, pancreas and duodenumo Perform Kocher maneuver (release the lateral and posterior attachments of the 2ndportion of duodenum)o Perform transcystic intra-op cholangiogramCHOLECYSTECTOMY (same procedure):o Intraoperative assessmentoo Oblique right subcostal incision, carried down to peritoneumo Sterile field preparedo Asepsis-antisepsis observedo Supine with padding at the posterior right upper quadrantCHOLEDOCHODUODENOSTOMYo Dry Sterile Dressingo Subcutaneous closed by inverted T sutures using Chromic 2-0

o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0o Layer by layer closureo Place a draino Complete counto Hemostasis doneo Irrigation with NSSo Check for anastomtic leako Side to side anastomosis in a single layer using interrupted silk 4-0o Make a transverse incision to the duodenum near to the CBD incisiono Anchor the duodenum to the CBD by placing a row of silk 4-0 suturesposteriorlyo Mobilize the CBD and duodenum adequatelyo CBD Explorationo Vertical incision is made between the sutureso Traction suture placed laterally and medially using silk 4-0o Site of choledochotomy identified and skeletonizedo Palpate the CBD, pancreas and duodenumo Perform Kocher maneuver (release the lateral and posterior attachments of the 2ndportion of duodenum)CHOLECYSTECTOMY (same procedure):o Intraoperative findings notedo Oblique right subcostal incision (may extend to the left “chevron incision”) carried downto peritoneumo Sterile field preparedo Asepsis-antisepsis observedo Patient supine with padding at the posterior right upper quadrantCHOLECYSTOJEJUNOSTOMYo Anchor the jejunum to the fundus of gallbladdero Identify the jejunal site for anastomosis about 30 cms from the ligamentof Treitz

o Open the gallbladder transversely and assess the patency of the cystic duct, remove anystoneo Intraoperative findings notedo Oblique right subcostal incision(may extend to the left “chevron incision”) or midlineincision carried down to peritoneumo Sterile field preparedo Asepsis-antisepsis observedo Supine with padding at the posterior right upper quadranto Dry Sterile Dressingo Skin closed subcuticularly using vicryl 4-0.o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0o Layer by layer closureo Insert a draino Complete counto Hemostasis doneo Irrigation with NSSo Check for anastomtic leako Perform the anastomosis in a single layer using interrupted silk 4-0sutureso Make a transverse incision on the jejunumSPHINCTEROTOMY / SPHINCTEROPLASTYo Dry Sterile Dressingo Skin closed subcuticularly using vicryl 4-0.o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0o Layer by layer closureo Place a draino Close the CBD over a T-tubeo Close the duodenum in 2 layers using silk 0o Hemostasiso Protect the pancreatic duct openingo Suture the ductal and duodenal mucosa with interrupted 5-0 syntheticabsorbable sutures

o Perform 5 mm sphincterotomy between the 10 and 11 o’ clock positionsusing scalpel blade or a pott’s scissoro At the 3 and 9 o’ clock positions in the periampullary area, place 5-0 silkstay sutureso Locate the ampullao Perform duodenotomy - vertical incision at the anti-mesenteric sideo Place stay sutures of silk 4-0 at the duodenotomy siteo Identify the duodenotomy site by passing bakes dilator into the CBDdown as guide to the location of the ampulla.o Carry out choledochotomy.CBDEo Palpate the CBD, pancreas and duodenumo Perform Kocher maneuver (release the lateral and posterior attachments of the 2nd

portion of duodenum)o Perform IOCCHOLECYSTECTOMY (same procedure)o Intraoperative assessmento Oblique right subcostal incision(may extend to the left “chevron incision”) carried downto peritoneumo Sterile field preparedo Asepsis-atnisepsis technique observedo Patient supine with padding at the posterior right upper quadrantDISTAL PANCREATECTOMYo Dry Sterile Dressingo Skin closed subcuticularly using vicryl 4-0.o Subcutaneous closed by Inverted T sutures using Chromic 2-0o Ant.rectus sheath and fascia - continuos interlocking -Vicryl-0o Peritoneum and post.rectus sheath - continuos interlocking -Vicryl-0o Layer by layer closureo Insert a drain (close suction drain)o Complete counto Hemostasis doneo Irrigation with NSSo Close the cut edge with interrupted sutures silk 3-0

o Identify the pancreatic duct and close with mattress suture.o Transect the pancreaso Identify the site of resectiono Mobilize the inferior border of pancreas extending posteriorlyo Mobilize the pancreas by incising the peritoneum on the superiorborder, protect the splenic arteryo Release the tail from the spleen and develop a plane in betweeno Assess the extent of the resectiono Assess the entire pancreaso Retract the stomach upward, and the transverse colon downwardo Open the entire lesser sac by releasing the gastrocolic ligamento Palpate the entire abdomeno Midline incision or oblique left subcostal incision extended to the right and carrieddown to peritoneumo Sterile drapes placedo Asepsis-antisepsis technique observedo Patient supineWHIPPLE’S PROCEDUREo Distal CBD transected near duodenumo cholecystectomy doneo right gastric artery identified and ligatedo gastroduodenal artery identified and ligatedo distal CBD exposedo Hepatic artery identified and skeletonizedo Extensive Kocher maneuver done from foramen of Winslow superiorlyup to as far as the point where SMV crosses the transverse (3rdportion) duodenumo Dissection of portal vein and superior mesenteric veino Resectability assessedo Intaoperative findings notedo Midline incision carried down from skin to peritoneumo Sterile drapes placedo Asepsiis-antisepsiso Patient supine

o Layer by layer closureo Complete counto Hemostasiso Peritoneal washingo Drains inserted over hepatico-J and pancreatico-J anastomosiso Tube jejunostomy insertedo Jejunojejunostomy (2 layer)o Gastrojejunostomy using a Roux en Y technique (2 layer)o End to side hepaticojejunal anastomisis about 8 cms away frompancreatico-jejunal anastomisis (2 layer technique)o End-to-end pancreatico-jejunal anastomosis by invagination done with a feeding tubeinserted into the pancreatic duct and exit into the jejunum 30 cms away, alongantimesenteric wall and brought out thru the skin (2-layer technique)o Dissection and Division of Proximal Jejunumo Uncinate process divided with electrocautery, edges sutured usingcontinuous interlocking technique with silk 4-0o Ligation of the superior and inferior pancreatic arteryo Neck and the body of the pancreas freed from underlying splenic veinfrom aboveo Division of Pancreas about 3 cms from left of SMVo stomach transectedo Identify site of gastric transectiono Ligate the gastroepiploic arcade along greater curvature of stomacho Left gastric artery identified and ligatedo Gastric dissectionSPLENECTOMYo Dry sterile dressingo Skin – Silk 4-0o Fascia - continuous interlocking suture using Vicryl 0o Abdominal closureo Correct counto Irrigation done

o Hemostasiso spleen removed, small feeding vessels ligatedo the tail of the pancreas protectedo Individual ligation of the splenic vessels doneo hilum dissectedo short gastric vessels ligatedo splenophrenic, splenorenal and splenocolic ligaments ligatedo spleen mobilizedo splenic artery identified and ligated proximallyo gastrocolic omentum openedo Intraoperative findings notedo Midline incision carried down from skin to peritoneumo Sterile drapes placedo Asepsis-antisepsiso Patient supinePORTOCAVAL SHUNTo Dry sterile dressingo Skin – Silk 4-0o Fascia - continuous interlocking suture using Vicryl 0o Abdominal closureo Correct counto Irrigation doneo Hemostasiso Anastomose the portal vein to the inferior vena cava using 6-0polypropylene continuous sutureo Oversew the hepatic portal stump with 5-0 polypropyleneo Divide the portal vein near the hepatic side (if end to side)o Runnjing 4-0 vascular suture used for the anastomosiso A side to side anastomosis or end to side portocaval shunt performedo IVC skeletonizedo Mobilization of the inferior vena cava by reflecting the duodenum to theleft (Kocher maneuver)o Isolation and mobilization of the portal veino Portal triad exposedo Intraop findings noted

o Midline incision carried down from skin to peritoneumo Sterile drapes placedo Asepsis-antisepsis observedo Patient supineSPLENORENAL SHUNTo the distal end to side of the left renal vein anastomosed usingo the hepatic end of the splenic vein oversewno the splenic vein divided at the junction with the superior mesenteric vein.DISTAL SPLENORENAL SHUNT:o Retroperitoneal dissection, left renal vein isolated and mobilized fromthe inferior vena cava to the hilum of the kidneyo Splenic vein mobilized, small tributary veins ligatedo Incise the peritoneum in the inferior surface of the pancreas andupwardly retract the body of the pancreaso Preserve the short gastric vessels to the hilum of the spleeno Divide the greater omentum between the greater curvature of thestomach and the transverse colono Retract the small bowel forward and to the righto Mobilize the transverse colon down to the splenic flexure and proximaldescending colono Intraop evaluation madeo Midline incision or bilateral subcostal approach carried down from skin toperitoneumo Sterile drapes placedo Asepsis-antisepsis observedo Patient supinecontinuous 6-0 polypropyleneo Dry sterile dressingo Skin – Silk 4-0o Fascia - continuous interlocking suture using Vicryl 0o Abdominal closureo Correct counto Irrigation doneo Hemostasis

o Ligation of the left gastric (coronary) vein and the right gastroepiploicveino Anastomosis of the proximal end to side of the left renal vein done usingcontinuous 6-0 polypropyleneo the splenic end of the splenic vein oversewno splenic vein divided near the hilum of the spleenPROXIMAL SPLENORENAL SHUNT:HEPATIC RESECTION (RIGHT LOBECTOMY)o Layer by layer closureo Suction drain placedo Hemostasis and bile stasiso right lobe of liver removedo Parenchyma of caudate process transected to expose the anterior surface of the inferiorvena cavao Middle hepatic vein ligated during the parenchymal resectiono Smaller bile ducts & vessels ligated on the resected side of livero Parenchyma transected on the line of vascular demarcationo right hepatic vein transected with running silk 1-0 sutureo Main right hepatic vein is dissected from the inferior vena cava and livero retrocaval ligament bridging segments 1 and 7 dividedo main right hepatic vein exposedo Multiple small short hepatic veins between inferior vena cava and segments 1, 6, and 7 aare ligatedo Right lobar portal vein branch freed from surrounding lymphoareolar tissue and ligatedo Right portal vein exposed from right of the hepatoduodenal ligamento portal vein bifurcation exposedo Lymphatic vessels around hepatic artery ligatedo Right hepatic artery doubly ligated with silk 1-0 and dividedo Hepatoduodenal ligament incised longitudinally posterior to the bile duct

RIGHT LOBECTOMY:o cholecystectomy doneo the gastrohepatic omentum dividedo ligamentum teres hepatis and falciform ligament dividedo the liver mobilized from the hepatic flexureo Intraoperative evaluationo Bilateral oblique subcostal incision (chevron) carried down to peritoneumo Sterile drapes placedo Asepsis-antisepsiso Patient supineINGUINAL HERNIORRHAPHYo Dry sterile dressingo Skin - subcuticular with vicryl 4-0o Closure of the external oblique aponeurosis with vicryl 2-0 continousinterlockingo Wound closureo Complete counto Hemostasiso conjoined tendon sutured to the inguinal ligament (shelving edge) frompubis to internal ringo Distal part of the sac left open after hemostasiso High ligation of the proximal saco Reduction of contento Proximal part is dissected up to the internal ring and laterally to the deepepigastric vesselso hernial sac skeletonized, opened, and transectedo sac located anterior to the spermatic cordo spermatic cord isolated and retracted with an umbilical tapeo ilioinguinal nerve identified and sparedo external oblique aponeurosis opened along its fibers down to the eternalringo Large veins ligated ( superficial epigastric )o Incision carried down to fasciao Oblique inguinal incision parallel to the inguinal ligamento Sterile drapes placedo Asepsis-antisepsis

o Patient supineHERNIOPLASTYo Prolene mesh, placed under spermatic cord, 3-4 cm larger than theo Distal part of the sac left open after hemostasiso High ligation of the proximal saco Proximal part dissected up to the internal ring and laterally to the deepepigastric vesselso Hernial sac skeletonized, opened, and transectedo Hernial sac located anterior to the spermatic cordo spermatic cord isolated and retracted with umbilical tapeo ilioinguinal nerve identified and sparedo external oblique aponeurosis opened along its fibers down to the eternalringo Large veins ligated ( superficial epigastric )o Incision carried down to fasciao Oblique inguinal incision parallel to the inguinal ligamento Sterile drapes placedo Asepsis-antisepsiso Patient supinedefect circumferentiallyo Dry sterile dressingo Skin - subcuticular with vicryl 4-0o Close the external oblique aponeurosis with vicryl 2-0 continuousinterlockingo Wound closureo Correct counto Hemostasiso Cut the mesh and snug cut edge to the spermatic cordo Prolene mesh sutured with silk 2-0 with interrupted mattress around theperimeter, anterior rectus sheath, rectus muscle, and transversalis fasciaalong medial aspect and to the inguinal ligament laterallyooooREPAIR OF UMBILICAL HERNIAo Dry sterile dressingo skin - silk 3-0 simple interrupted

o subcutaneous tissue - chromic 2-0 simple interruptedo Wound closureo Drain if neededo Correct counto Hemostasiso Primary closure of the fascia using Vicryl 0 continuous interlocking withinterrupted silk 0o hernial sac removedo Reduction of hernial sac contents into the abdominal cavityo hernial sac then opened, adhesions released intraperitoneallyo entire circumference of the defect exposedo The hernial sac identified and dissected towards the fascial defecto Curved infraumbilical incision carried down to subcutaneous tissueo Sterile drapes placedo Asepsis-antisepsiso Patient supineBillroth Io Dry sterile dressingo Skin – Silk 4-0o Fascia - continuous interlocking suture using Vicryl 0o Abdominal closureo Correct counto Irrigation doneo Hemostasiso Anastomosis reinforced with omentumo A 3 suture bites at the lesser curvature area placed ( anterior stomach,posterior stomach and duodenum) using silk 3-0o Anastomosis of the gastric opening to the duodenum (2 layers) usingchromic 3-0 continuous as first layer followed by 3-0 silk interrupted as2nd layero Partial closure of the gastric opening at the lesser curvature (2 layers)using chromic 3-0 continuous as first layer followed by 3-0 silkinterrupted as 2nd layero Duodenum transected just below the pyloric ring

o Stomach transected over a clampo Line of gastric transection identifiedo dissection continued toward the left gastric arteryo right gastric artery ligatedo vessels of the lesser curvature ligatedo dissection carried out to the gastroduodenal area , small feeding vesselligatedo gastroepiploic vessels ligatedo gastrocolic ligament incised and transverse colon retracted downwardo Ligation of arteries and veins of the greater curvature distal to the pointof the gastric transectiono Mobilize the distal stomacho Intaoperative findings notedo Midline incision carried down from skin to peritoneumo Sterile drapes placedo Asepsis-antisepsiso Patient supineSUBTOTAL DISTAL GASTRECTOMY (Billroth II)o gastric opening anastomosed to the loop of jejunum (2 layers) using a runningo Proximal jejunal loop brought up in an antecolic fashiono Partial closure of the gastric opening at the lesser curvature sideo Duodenal stump iclosed in two layers with chromic 3-0 and silk 3-0o specimen removedo Duodenum transected just below the pyloric ringo Stomach transected over a clampo Line of gastric transection identifiedo dissection continued toward the left gastric arteryo right gastric artery ligatedo vessels of the lesser curvature ligatedo dissection to the gastroduodenal area carried out , small feeding vessel ligatedo gastroepiploic vessels ligatedo gastrocolic ligament incised and transverse colon retracted downwardo arteries and veins of the greater curvature distal to the point of the gastric

transaction ligatedo Distal stomach mobilizedo Intaoperative findings notedo Midline incision carried down from skin to peritoneumo Sterile drapes placedo Asepsis-antisepsiso Patient supine3-0 chromic for the mucosa and interrupted 3-0 silk seromuscularo Dry sterile dressingo Skin – Silk 4-0o Fascia - continuous interlocking suture using Vicryl 0o Abdominal closureo Correct counto Irrigation doneo HemostasisTOTAL GASTRECTOMYo Dry sterile dressingo Skin – Silk 4-0o Fascia - continuous interlocking suture using Vicryl 0o Abdominal closureo Correct counto Irrigation doneo Hemostasiso opening of the proximal jejunum anastomosed to the jejunal loop in twolayers (end to side)o end to side or end to end anastomosis with 2 layer sutureso distal end to the esophageal stump elevated without tensiono proximal jejunum divided about 15 cms from ligament of Treitzo A roux en Y esophagojejunal anastomosis performedo stomach removedo abdominal esophagus divided, stay sutures placed on each side of theesophaguso Duodenal stump closed in two layers with chromic 3-0 and silk 3-0o duodenum dividedo entire stomach mobilized from the gastroesophageal junction to theproximal portion of the duodenumo right and left gastric arteries ligated

o lesser omentum opened and removedo short gastric vessels ligatedo right and left gastroepiploic vessels ligatedo upward dissection of the greater omentum continuedo greater omentum separated from the transverse colono gastroesophageal area released and abdominal esophagus mobilizedo Intaoperative evaluation for operabilityo Midline incision carried down from skin to peritoneumo Sterile drapes placedo Asepsis-antisepsiso Patient supineVAGOTOMYo Intraoperative evaluationo Midline incision carried down from skin to peritoneumo Sterile drapes placedo Asepsis-antisepsiso Patient supineTRUNCAL VAGOTOMYo (Right) posterior vagus nerve palpated and identified, segment of thenerve removed, the proximal and distal ends ligatedo (Left) anterior vagus nerve identified & a segment of the nerve removed,proximal and distal ends ligatedo anterior esophagus skeletonizedo peritoneum incised at the gastroesophageal junctiono abdominal esophagusPROXIMAL GASTRIC VAGOTOMYo Dry sterile dressingo Skin – Silk 4-0o Fascia - continuous interlocking suture using Vicryl 0o Abdominal closureo Correct counto Irrigation doneo Hemostasiso Re-peritonealization of the lesser curve doneo Dissection continued toward the incisura angularis

o Starting approximately 6 cm from the pylorus, the neurovascularelements were divided and ligated between the inner curve and thenerve of Laterjeto distal half of the lesser curvature mobilizedo nerves of Laterjet localized, hepatic and celiac divisions protectedo right and left vagus nerves identifiedo abdominal esophagus mobilizedPYLOROPLASTYo Patient supineo Asepsis-antisepsiso Sterile drapes placedo Midline incision carried down from skin to peritoneumo Intraoperative evaluationHEINEKE-MIKULICZ techniqueo Pyloric area identifiedo longitudinal pyloroduodenal incision about 5cm in lengtho Wound closed transversely in 2 layers using 3-0 absorbable suture and 3-0 silkFINNEY techniqueo Pyloric area mobilized down to the 2nd portions of the duodenumo site for pyloroduodenal incision identifiedo pyloric area of the stomach sutured to the 1st portion of the duodenumwith interrupted lembert suture using 3-0 silk,o U shaped pyloroduodenal incision made including the distal pyloricantrum and the proximal 2nd portion of the duodenumo Gastroduodenal opening closed in 2 layerso Hemostasiso Irrigation doneo Correct counto Abdominal closureo Fascia - continuous interlocking suture using Vicryl 0o Skin – Silk 4-0o Dry sterile dressingGASTROJEJUNOSTOMYo Dry dressing

o Skin by simple interrupted suture using silk 4-0o Fascia by continuous suture using vicryl 0o Abdominal wall closureo Complete hemostasis and sponge counto A 4-0 seromuscular Lembert suture (2nd layer) placedo posterior mucosal layer approximated using 3-0 Vicryl, as a continuous locked suture,penetrating both mucosal and seromuscular coats towards the anterior margin bycontinuous Connell-type suturingo A 5cm incision placed on the antimesenteric border of jejunum and along greatercurvature of stomacho Lembert suture of 3-0 silk placed on seromuscular coats of stomach and jejunum forabout 5 cmo longitudinal scratch mark made on the antimesenteric border of jejunum, beginning at apoint 12cm from ligament of Treitz, about 5cm in lengtho Ligament of Treitz identified and jejunum brought in an antecolonic fashiono Midline incision carried down to peritoneumo Sterile drapes placedo Asepsis-antisepsiso Patient supineBELOW THE KNEE AMPUTATIONo Immobilization using plaster splinto Suture line covered with sterile dressingo Dog ears carefully tailored.o Skin approximated carefullyo Superficial fascia sutured with interrupted absorbable sutureso Simple myodesis approximating the calf muscles over the bone endso Hemostasiso Muscles assessed for viabilityo Wound irrigated with betadine wash

o Anterior aspect of tibia rounded and beveled to avoid bony prominence in the stumpo Posterior flap madeo Tibia divided perpendicularly to its long axis with a hand or power bone sawo Fibula divided 1cm proximal to the intended line of division of the tibia to forma aconical shape to the stumpo Neurovascular bundle doubly clamped, divided, and ligated, with excessive tractionavoidedo Muscle bellies divided sharply/ electrocauteryo Skin, subcutaneous tissue, and superficial fascia incised sharply in chosen configurationo Sterile drapes placedo Asepsis-antisepsiso Patient supineARTERIO-VENOUS FISTULAo Wound closed with subcuticular sutureso Thrill palpatedo Upon completion of anastomosis, knot at midpoint anteriorlyo Back wall sutured first from within the vesselso Continuous 7-0 suture used to crate a side-to-side anastomosiso Arteriotomy then made similarlyo Incision then extended 7-9 mm with tenotomy scissorso Vein incised longitudinally with a pointed bladeo Each vessel branch or tributary ligated at least a millimeter away from the main vesselo Radial artery and cephalic vein mobilized sufficiently to bring them together withoutangulation or tensiono Sterile drapes placedo Asepsis-antisepsiso Patient supine under local anaesthesiaExploratory 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 procedurePrimary 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 dressingCHIELOPLASTY 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 nasalvestibule down to the piriform aperture frees the nasal ala to advance mediallyindependently of the lip. Incision for the interdigitation of this flap medially just above the vermilion cutaneousjunction is not made until satisfactory approximateion of the major flaps. The lateral and medial lip segments are freed by sharp dissection from the underlyingmaxilla in a supraperiosteal plane. Cleft edge mucosal flaps was excised when the alveolar ridge is intact and rotatedupward 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 noseto avoid a raw surface at this point. The mucosal surface sutured using a 4-0 Vicryl that grasps the lip muscle back along theupper edge of the advancement flap as well as along the depths of the back cut of therotation 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 junctionand advancing toward the mucosa Dressing done End of ProcedureUranoplasty

Patient supine under general inhalation anesthesia Asepsis and antisepsis Sterile drapings placed Dingman retractor placed, the cleft margins, adjacent hard palate, and retromolar areasare 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 andpreserved. The vomer flap is kept continuous posteriorly with the nasal mucosa layer of the softpalate. Muscle fibers are dissected from the soft palate nasal mucosa for 1 to 1.5 cm. Themedial edges of the soft palate are sutured using vicryl 4-0 Mucoperiosteum is tightly bound down to the maxillary palatine suture and must befreed 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 procedureZ - 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 insertedinto 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 nasalvestibule down to the piriform aperture frees the nasal ala to advance mediallyindependently of the lip. The lateral and medial lip segments are freed by sharp dissection from the underlyingmaxilla 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 theupper edge of the advancement flap as well as along the depths of the back cut of therotation incision The skin was sutured with ethilon 6-0, beginning at the vermilion cutaneous junctionand advancing toward the mucosa Dressing done End of Procedure