CVP INSERTION

Patient positioned supineAsepsis/AntisepsisDrapings doneInfiltration of local anesthesiaIncision done proximal to the cubital area done, deepenedIsolation of basilica vein doneVeinotomy, cannulation with Fr. 8 feeding tube, patency checkedDistal portion of the vein ligatedFeeding tube anchored, three-way stop cock hooked and attached to mano meterSkin closure with silk 3/0Top dressing doneEnd of procedure.

I AND D SUTURING OF WOUND

Patient positioned supineAsepsis/AntisepsisDrapings doneInfiltration of local anesthesiaIrrigation/debridement of lacerated wound (location)Suturing of wound with nylon 4/0Betadine paintTop dressing doneEnd of procedure.

AVF CREATION

Patient positioned supine with L arm laterally extendedAsepsis/AntisepsisDrapings doneInfiltration of local anesthesiaIncision done over forearm, deepenedLocalization of radial artery, isolatedVein ligated at distal portion, proximal portion approximated to the arteryArteriotomy done, then AV fistula created, using nylon 6/0 double armBleeding checked, hemostasis, bruit checked and appreciatedClosure of skin with nylon 6/0 - matressTop dressing doneEnd of procedure.

Fistulotomy

Induction of spinal anesthesiaPatient placed in dorsal lithotomy positionAsepsis/Antisepsis/DrapingsAnoscopy doneErguson retractors appliedExternal openings probed and noted tract leading towards the anal mucosaFeeding tube with peroxide solution inserted in the external opening to identify the internal opening in the anal mucosaFistula probe inserted and tract identified, unroofed with cold and warm knifeExternal opening excisedTract debrided with curetteHemostasis Perieal mole excisedPalmar wart in the thumb of R hand cauterizedTop dressings with Povidine Iodine and Operative spongesEnd of procedure.

CTT

Patient positionedIdentification of the 5th ICS in the Axillary lineSterile prepand drapings doneInfiltration of lidocaine anesthesia at a level below the pre-marked 5th ICSA horizontal skin incision done & deepened down to the subcutaneous fat with the kelly clamp a tract is created from the incision site superiorly posteriorly & immediately above the superior edge of the 6th ribs avoiding injury to the neurovascular bundleUpon entering the pleural space, a gloved finger is placed through the tract into the pleural spacePalpation to the lung to confirm pleural cavity location & assuring no adhesions are presentProximal end of the chest tube is grasped with a Kelly clamp and both inserted through the subcutaneous tract into the pleural cavity directing the tube posteriorly towards the apexTube attached to water sealed bottle & securely anchored to the skin with silk suturesVaselined gauze placed around the tube to sealTop dressings doneEnd of procedure.

CLOSE TUBE THORACOSTOMY R

Patient positioned supineAsepsis/AntisepsisDrapings doneInduction of anesthesiaIncision done at R anterior auxillary line 6th ICSBlunt dissection of the muscles up to the intercostals

Pleural puncture doneInsertion of chest tube Fr 32 guided by the index finger, positioned in placeRubber tubing attached to the chest tube, initial straw-colored drain ~__cc, then attached to thoracostomy bottleTube anchored to skin with silk0skin closure with silk 3/0Top dressing doneEnd of procedure.

PD Cathetererization/ Tencknoff

Induction of anesthesiaPatient positioned supineAsepsis/AntisepsisDrapings doneSkin incision done R parerectus 5cm from & below the umbilicusIncision deepened down to the peritoneum, muscles splitPurse string sutures placed using vicryl 3-0Peritoneum penetrated & Tencknoff catheter inserted catheter left intraperitoneallyFascia & Rectus muscles approximated using vicryl 2-0 figure of 8Skin closed w/ silk 4-0, simple mattressBetadine paintTop dressings doneEnd of procedure.

IJ catheter insertion

Patient positioned supineAsepsis/AntisepsisDrapings doneInfiltration of local anesthesiaSildinger need inserted to the needle, needle removed leaving the guidewireDilator inserted, dilating internal jugular site and jugular veinJo-line inserted catheter inserted into the guidewire, guidewire removedPatency checked, infiltration of heparin on catheter tip, lockedCatheter anchored with silk 3-0Top dressing doneEnd of procedure.

Pericardiostomy Tube Insertion

Induction of anesthesiaPatient positioned supineAsepsis/AntisepsisDrapings doneVertical incision done from the xiphisternal junction down to the tip the xiphoid processBlunt dissection is done to define the retrosternal planePericardium approached extraperitoneallyPericardium opened by a scalpelFluid control-sunctionedPericadiostomy tube inserted, exteriorized separate from incision siteTube attached to closed tube systemClosure Tube secured with suturesTop dressings with Povidine-Iodine and operative spongesEnd of procedure.

External fixation

Patient positionedWadding sheet applied from foot to proximal legPlaster of Paris wet and applied in circular manner Molded and allow to dryEnd of procedure.

Excision with Frozen Section Biopsy

Patient positioned supineInduction of anesthesiaAsepsis/AntisepsisDrapings done exposing the incision areaIncision done on RUQExcision of (size & char) mass on R breastBleeders controlled, hemostasis done as controlledSkin closure using _____Betadine paint Top dressingEnd of procedure.

Tracheostomy Tube Insertion

Patient positioned supineAsepsis/AntisepsisDrapings doneInfiltration of local anesthesiaSkin incision done horizontally over the 2nd to 3rd tracheal ringIncision deepened down to the subcutaneous fat and platysma

muscle & exposing the sternohyoid musclesHemostasisElevation of the strap muscles done, making a vertical incision in the

midline separating these two strap musclesIncision was carried down to the upper trachea, exposing & dividing the

capsule of the thyroid gland

needle

vein

The isthmus as it crosses the trachea is retracted in the cephalad direction revealing the 2nd & 3rd tracheal ring

Incision of the 2nd & 3rd tracheal ring done providing adequate tracheostomy opening

Cuffed endotracheal tube inserted into the tracheal incision, while the endotracheal is extracted

Silk suture placed through the incision site on each sideTracheostomy dressing doneEnd of procedure.

MRM

Induction of anesthesiaPatient positioned supineFoley catheter insertion doneAsepsis/AntisepsisDrapings done leaving the operative site exposedStewart skin incision done, extending down perpendicular to the

Subcutaneous plane with 5-8 mm thicknessSkin &subcutaneous flaps developed.

Superiorly up to the subclavius muscleInferiorly up to the caudal extension of the breast 2 cm inferior to the inferior to the inframammary fold Medially up to the midline of the sternumLaterally up to the anterior margin of the latissimus dorsi

Bleeders clamped and ligated between suturesBreast Tissue removed at the Pectoralis Major Fascia above the

Pectoralis Musculature using the electrocautery and scalpelPerforator vessels clamped, ligated between silk suturesBreast & skin elevated pectoralis fascia from the lateral humeral extension to the medial costochondrial junction, are elevated en blocThe lateral flap is elevated to the anterior margin of the latissimus dorsiLoose areolar tissue of the lateral axillary space elevated with identification of the lattermost extent of the maxillary veinDissection proceeds medially identifying the Long thoracic nerve & preserved; thoracodorsal nerve likewise identified & preservedEntire breast & fascia are cleared medially & inferiorly from the aponeurosisof the rectus abdominis muscleOperating field carefully inspected & bleeding points identified, clamped & ligatedClosed sunction drain left in place at the axilla & brought out to separate skin siteSkin approximated with interrupted non-absorbable sutures, &

subcutaneous w/ vicryl 4-0Betadine paintTop pressure dressingEnd of procedure.

Modified Neck Dissection, Thyroidectomy

Induction of general anesthesiaPatient positioned with neck hyperextendedAsepsis/AntisepsisDrapings doneIncision deepeded to the areolar tissue plane just below the platysmaSharp dissection alternate with blunt dissection done to facilitate freeing of the

upper flap, isolation and excision of thyroid gland doneDissection progressed with the exposure of thevsternocleidomastoid, the

dissection then shifted to the posterior cervical triangle, exposing the borders of the trapezius muscles

Lower flap produced, application of tractionIdentification of the external jugular vein done and preserved, and

spinal accessory nerve identified and divided, dissection carried down to the superior aspect of the clavicle

Common carotid artery exposed, dissection continued inferiorly and extended superiorly, following the floor of the neck or the prevertebra fascia

All loose areolar tissue about the caritod artery removedSuperior dissection continued exposing the hypoglossal nerve, submental dissection done.

Traction of the maxillary gland done to expose lingual nerve, salivary duct and hypoglossal nerve.

Anterior belly of the omohyoid muscle is divided from the sling of the digastric muscle. Dissection completed after the posterior belly of the digastric muscle is exposedRetraction of the posterior belly of the digastric superiorly exposed the internal jugular vein,

vein clamped and divided.Internal jugular vein clamped high, dissection completed with the division of the

sternocleidomastoid in the mastoid process.Bleeders clamped and ligatedHemostasis done, washingPlatysma approximated and closedRelease of skin traction and closure doneDrain applied and left in placeSkin closure via subcuticular stitchTop dressing doneEnd of procedure.

TOTAL THYROIDECTOMY

Induction of general anesthesiaPatient positioned with neck hyperextendedAsepsis/Antisepsis/DrapingsIncision done dividing the skin and subcutaneous tissueIncision deepened to the areolar tissue plane just below the platysmaSharp dissection alternate with blunt dissection done to facilitate freeing of upper flapDissection reaching the thyroid notch, exposing the entire thyroid cartilage and downward to

the suprasternal notchLower flap produced, application of tractionPlane of cleavage between the sternocleidomastoid muscle and the outer boundaries of the

sternohyoid musclePlane develop with sharp and blunt dissection between the thyroid gland and sternohyoid

muscleBleeders clamped and ligatedRelease of thyroid gland at the superior pole by blunt dissectionVessels preserved, identification of the recurrent laryngeal nerve done and preservedRelease of thyroid gland at the middle and inferior pole done, identify the middle and inferior

thyroid vesselsIsthmus identified and released

Same procedure done at the contra-lateral thyroid lobeRelease of the entire thyroid gland doneHemostasis done, washingRelease of skin traction and closure doneDrain applied and left in placeSkin closure with vicryl 4/0 subcuticular stitchTop dressing doneSpecimen for histopathologyEnd of procedure.

VP Shunting

Induction of anesthesiaAsepsis/antisepsisDrapings done leaving operative exposed R parietal scalp incision done over the periosteumBurr hole craniotomy done. Dura exposed and incisedAbdominal skin incision done over the R pararectus muscle 3 cm above the umbilicusIncision deepened down to the peritoneumShunt passer inserted subcutaneously from the scalp incision towards the

abdominal incisionVentriculoperitoneal shunt guided through the shunt passer and shunt passer

pulled outShunt device anchored to the craniotomy, scalp closed with nylon 3-0Peritoneal end of the shunt left inside the peritoneumPeritoneum closed with vicryl 2-0Rectus muscles approximated with vicryl 3-0 using fig of 8Rectus fascia closed with vicryl 3-0 using continuous running sutures

Skin closed with simple interrupted sutures using silk 3-0Betadine paintTop dressing End of procedure.

Left Hemicraniectomy

Induction of anesthesiaAsepsis/antisepsisDrapings done leaving operative site exposedL parietal scalp incision done up to the periosteumBleeding controlled, hemostasis done as encounteredHoles borred through the cranium 2-3cm apartGigly wire guide passed through and wires passed, Cranium cut through the giggly wire, done at entire span of Left craniumCraniectomy done, dura exposed which is densedHemostasis with surgical and electrocauteryExposed dura closed with apposition of aponeurosisSkin closure with nylon continuous mattress sutureTop dressing doneEnd of procedure.

CRANIOTOMY CLIPPING ANEURYSM

Patient supineInduction of general anesthesiaCraniotomy prep done and drapings placed, secured with suturesL fronto-parietal incision done, deepened, traversing skin, subcutaneous tissue, dense connective tissue, epicranial aponeurosis, temporalis muscle loose connective tissue, periosteumClamps adequately placed, secured in groups with elastic bandsPeriosteum seperated from calvariaBleeders controlled as encounteredBurr hole made on points for otomy, dura left intact separated from inner table by dissector and wire guide, proceeded with Gigly wire cutting, calved separated from duraProtruding portions Rougeured offLeyla retractors applied, securedDissection done up to the level of the optic chiasmAnterior circulation of the Circle of Willis identifiedAnterior communicating artery identified, aneurysm locatedAneurysm clipped with permanent clips, wrapped with crayanoacrylate coat cellulose fiberProfuse irrigationHemostasisDuraplasty with vicryl 3-0Insertion of JP drain, exteriorized separate from incision site, secured with suturesCalvria replacedClosure of scalpConnective tissue, aponeurosis using vicryl 3-0 simple interruptedSkin, subcutaneously using nylon 3-0 vertical mattressBetadine paint

Top dressing done with OSEnd of procedure

Appendectomy Drop Method via Rocky Davis Incision

Induction of spinal anesthesiaPatient supineAsepsis/AntisepsisDrapings doneTransverse incision done at McBurney,s point (Rocky-Davis Incision)Incision deepened, traversing the skin, subQ, transversalis fascia, muscles and peritoneumHemostasisAppendix isolatedAppendiceal artery identified, clamped, cut, ligated with silk 3-0Appendix base clamped, cut and secured with use of purse string stitch using silk 3-0

External oblique with chromic 3-0Fascial closureSkin closure with nylon 3-0

Wound painted with povidine iodine Top dressing doneSpecimen for histopathologyEnd of procedure.

Appendectomy - Ruptured

Induction of anesthesiaFoley catheter insertion doneAsepsis/antisepsisDrapings done leaving operative site exposedRocky-Davis skin incision done over the R lower quadrantSkin incision deepened down to the peritoneumRetractors applied. Appendix identified and isolatedSee above intra op findingsAppendectomy done Drop MethodHemostasisDrain, penrose left at the R gutter & brought out through a separate incisionClosure done layer by layerPeritoneum closed with vicryl 1-0, continuous running suturesMuscles approximated w/ vicryl 1-0 continuous interlocking suturesSkin closed w/ vicryl 4-0 subcutaneouslyBetadine paintTop dressingEnd of procedure.

Craniotomy, Evacuation Hematoma

Induction of anesthesiaAspesis/AntisepsisDrapings done leaving the operative site exposedL parietal scalp incision done up to the periosteumCraniotomy done, Dura mater exposed and incisedEvacuation of blood/ blood clots doneFlushing in dural space with catheter until return flow is clearDura repaired, scalp closed with vicryl 3-0Skin closure with nylon continuous mattress sutureTop dressing doneEnd of procedure.

Craniotomy Tube Ventriculostomy

Patient supineInduction of general anesthesiaCraniotomy prep done and drapings placed, secured with suturesPrevious incision site of (L) ventriculostomy enteredVentriculostomy tube removed, needle inserted to assess flow of CSFInsertion of new tube done and attached to a collecting bag Profuse irrigationHemostasisClosure of scalp using silk 3-0 full thickness via Horizontal mattressTop dressing with povidine iodine and OSEnd of procedure.

ORT VP shunting

Induction of AnesthesiaAsepsis/ AntisepsisDrapings done leaving operative site exposedR Parietal scalp incision done to the periosteumBurr hole craniotomy done. Dura exposed and incisedAbdominal skin incision done over the R pararectus muscle

3 cm above the umbilicusIncision deepened down to the peritoneumShunt passer inserted subcutaneously from the scalp incision

towards the abdominal incisionVentriculoperitoneal shunt guided through the shunt passer and

shunt passer pulled outShunt device anchored to the craniotomy, scalp closed w/ nylon 3-0Peritoneal end of the shunt left inside the peritoneumPeritoneum closed with vicryl 2-0Rectus muscles approximated w/ vicryl 3-0 using fig of 8Rectus fascia closed w/ vicryl 3-0 using continuous running suturesSkin closed withsimple interrupted sutures using silk 3-0Betadine paintTop dressing

End of procedure.

Nephrectomy

Induction of anesthesiaPatient on L/R lateral decubitus positionAsepsis/antisepsisDrapings done leaving operative site exposedL/R lumbar incision, deepenedLumbosacral fascia openedKidney isolated from the perinephric fatRenal artery identified, clamped, cut, and ligatedHemostasisDrain placedClosure (lumbodorsal fascia/sub cutaneous skin)Top dressing doneEnd of procedure.

Pyelolithotomy

Induction of anesthesiaPatient placed in the standard flank position, table is broken, and tapes are placed to secure the patientAsepsis/antisepsisDrapings doneSubcostal incision is done started at the lateral border of the sacrospinalis muscle 1 cm below the lower edge of the 12th rib and follow the lower border of the rib anteriorly, ending at the lateral border of the rectus muscleIncision deepened through subQ, fascia down to the latissimus dorsi muscle and serratus posterior inferior muscles from their anterior free borders, then the external and interior oblique at their posterior free bordersLumbosacral fascia identified, sharply incised well posteriorly, transversalis muscle then identified, incised and split, exposing the peritoneum and pushed anteriorly Posterior layer of the lumbosacral fascia is then incised from the anterior border of the sacrospinalis muscleRetractors appliedPerirenal fat is then separated from the underlying pelvic area of the kidney, and the posterior surface id gently exposedUpper ureter is identified and an identi-loop is wrapped around it, and connection with the pelvis in the renal sinus is tracedPelvis is incised open, and the lithiasis is extracted in otoFlushing of the pelvocalyceal system done to expect remaining lithiasisHemostasis Renal pelvis is repaired via continuous stich using chromic 4-0 suturesClosed suction drain is placed around the pelvis and exteriorized separate from the incision site, tube secured to the skin with suturesTable is then broken to further coaptation of tissue edgesClosure layer by layerLumbodorsal fascia prolene 0 continuousInternal and external oblique vicryl 0 continuous Lastissimus dorsi, serratus posterior vicryl 0 continuousSubQ plain 2-0 simple interruptedSkin vicryl 3-0 subcuticular Top dressing with Povidine iodine and operative spongesEnd of procedure.

EXLAP

Patient positioned supineAsepsis/antisepsisDrapings doneAbdominal midline sutures removed up to the peritoneumAbdomen explored, previous anastomotic site intact with no peri-anastomotic fluid collectionDilated afferent loop from the previous gastro-jejunostomy and adjacent jejunum sutured together with anchor sutures of silk 3-0Jejuno-jejunostomy done with silk 4-0 sero-muscular layer sutured simple interrupted and vicryl 4-0 mucosal layer sutured via Gambee techniqueAdhesiolysisLavage done Tube jejunostomy attachment to peritoneal wall securedNGT (Fr 18 feeding tube) inserted and threaded to bypass the anastomosisHemostasisInsertion of passive (Penrose) drain and placed on the anastomotic sites, exteriorized separate from the incision siteClosurePeritoneum rectus sheath using Prolene 0 continuous external retention suturesFascia using Prolene 0 simple with bumpersSkin using silk 3-0 vertical mattressTop dressing with Povidine iodine and operative spongesEnd of procedure.

Laparoscopic Cholecystectomy

Patient positioned supineAsepsis/ antisepsisDrapings doneIncision is made in the umbilicus and dissected up to the level of the

peritoneum and openedHasson cannula is then inserted and carbon dioxide is insufflated and adequate

pneumoperitoneum is establish fixed, laparascope with the attached video camera is passed through the umbilical port

Abdomen exploredAdditional ports are then placed under direct vision; a 10mm port is placed in epigastrium, and

another 5 mm port in the midclavicular line, right

Thigh the lateral port, the gallbladder fundus was grasped and the hepatocystic triangle is identified and dissected

Incisions freed using electrocauteryCystic artery was identified and 2 proximal and 1 distal clips were applied

cystic artery was then cutCystic duct was identified and 2 proximal and 1 distal clips were applied,

cystic duct cutGallbladder freed from the liver bed using blunt and hot dissectionHemostasisGallbladder was then delivered through the epigastric port

Closure of wound was then done using vicryl 2-0 on the fascia and nylon 3-0 subcuticular stitch on the skin

Top dressing with Povidine iodine and oprative spongesEnd of procedure.

Lap converted to Open Cholecystectomy

Patient positioned supineInduction of general anesthesiaAsepsis/ antisepsisDrapings doneAn incision is made in the umbilicus and dissected up to the level of the

peritoneum and openedA Hassons cannula is then inserted and carbon dioxide is insufflated and adequate

pneumoperitoneumIs establish, fixed, laparoscopic with the attached video camera is passes through the umbilical

partAbdomen explored2 additional ports are then placed under direct vision, a 10mm port is placed

the epigrastrium, and another 5 mm port in the midclavicular line, rightThrough the lateral port, the gallbladder fundus was grasped and the hepatocystic triangle is

identified and dissectedCystic artery was identified and 2 proximal and 1 distal clips were appliedCystic artery was then cutAn aberrant vessel was then noted, after transecting the artery, and this produced brisk

bleeding in the operative field, the bleeder was identified but there was difficulty in clamping due to the pooling of blood and inadequacy of the suction to clear the hepatocystic triangle is identified

Laparoscopic surgery abortedR subcostal Kochers incision is then made, traversing skin subcutaneous tissue,

anterior rectus sheathRectus muscle cut with electrocautery, and posterior rectus sheath,

pre-peritoneal fat, peritnoneum openedGallbladder and hepatoduodenal ligament exposed alier retractors were

placed and the GB fundus was lifted upBetadine paintTop dressingEnd of procedure.

Cholecystectomy

Patient positioned supineInduction of general anesthesiaFoley catheter insertion doneAsepsis/ antisepsisDrapings done leaving operative site exposedTransverse oblique, skin incision done over R subcostal areaSkin incision deepened exposing the gallbladderPls see above intra op findingsHepatoduodenal peritoneum excise exposed & isolating the

cystic duct & Cystic arteryCystic artery divided between 2 silk ligaturesCystic duct isolated, divided between 2 silk ligaturesGallbladder dissected form the liver bed, hemostasisWashing with PNSS & suctioned out hemostasisPeritoneum and posterior rectus approximated w/ vicryl 1, continuous running suturesAnterior rectus fascia approximated w/ vicryl 1, continuous interlocking suturesFascia closed w/ plain 2-0 figure of 8 suturing Skin closed w/ vicryl 4-0 subcutaneouslyBetadine paintTop dressing doneEnd of procedure

Chole, IOC, CBDE, T-Tube

Patient positioned supineInduction of general anesthesiaAsepsis/ antisepsisDrapings doneMidline incision doneSkin incision deepened up to the peritoneumRetractors applied exposing the gallbladder and the anti-mesenteric

border of the bowelLongitudinal incision of the fundus of the gallbladder the anti-mesenteric

boerder of the bowelAnastomosis of the fundus of the gallbladder and anti-mesenteric border of the bowel sutured in place using Conell sutureIsolated jejunum, anchored to the gastric wall of the fundus and sutured Incision at the posterior gastric wall and proximal portion of the jejunumAnastomosis of the proximal portion of the jejunum and the posterior portion of the gastric wall and sutured in placing using Conell sutureWedge biopsy of the pancreatic body tumor doneLigation of blood vesselsWashingClosureTop dressingEnd of procedure.

Puff Through

Patient positioned supineInduction of general anesthesiaAsepsis/ antisepsisDrapings doneDilators serialty inserted up to maximum allowable sizeInscision made just above the dentate line, freeing the mucosal layer from

underlying muscle layer Mucosa fixed accordingly while circumferentially freeing the mucosaPortion of muscularis sent for frozen section biopsyMucosal tube dissected down to the perineumMucosa is freed from submuscusal layerBleeders controlled as encounteredIncision extending down to the level of colonBiopsy doneTransition zone noted and dissected futher proximally just about the

same length as the mucosal tubePortion of ganglionic segment of colon fixed to seromuscular cuff as it is circumferentially up to

the adequate level of colon End to end anastomotic done of pulled through segment of colon and the mucosal layer of the

rectumat the level of thedentate line with interrupted stitchTop dressing with Povidine Iodine and operative spongesEnd of procedure.

Transverse Loop Colostomy

Patient positioned supineInduction of general anesthesiaAsepsis/ antisepsisDrapings doneRUO incision, transverseA knuckle of transeverse colon was delivered into the wound, omentum

retracted upwardOmentum is divided over the presenting portion of the transeverse colon,

reflected to either sideInsertion of rubber catheterRubber catheter tip is cut off and one end inserted into the other pointFat tabs on the loop of bowel were anchored to adjacent peritoneum Peritoneal opening was partially closed by interrupted suturesSkin and SubQ closedPlacement of colostomy bag Dressing doneEnd of procedure.

LOW ANTERIOR RESECTION, STAPLED ANASTOMOSIS AND DIVERTING ILEOSTOMY

Induction of anesthesiaAsepsis/AntisepsisDrapings done leaving operative site exposedMidline skin incision done 2cm above the umbilicus extending done

to the suprapubic area Incision deepened to the peritoneumRetractors applied (see intra-op findings)Sigmoid & transverse colon mobilized small bowels walled off and

self-retaining retractors appliedPeritoneum of the pelvic colon is freed form region of the sigmoid down

to the other sidePeritoneum divided anteriorly to the rectum at the level of the base of the other sidePeritoneum further mobilized and surgeon passes R hands posteriorly

do to the hollow of the sacrumRectum freed posteriorly and anteriorly by blunt finger dissectionBlood supply to the distal segment of the inferior hemorrhoidal vessels &

inferior mesenteric artery ligatedAnastomosis clamped, applied below gross lower limits of the mass &

another clamp applied across previously prepared site proximal to the mass

Bowel divided between clampsLateral peritoneal attachment further divided from the left colon up to

transverse colon freeing the splenic flexureAbsorbable traction suture placed to serve as stay suture to the end of the

rectum and pursestring suture placed to closed end of the rectumPursestring suture tied snuggly around shaft of open staplerAnother pursestring suture applied at the end of the proximal sigmoid by

same technique used for rectal stumpOpen end of the sigmoid gently manipulated over the end of the anvilAssistant tightens clamp form below and surgeon form above prevents

fatty tissues form being trapped between lower endsAssistant verifies if stapler is tightened to the correct thickness for height

ABDOMINOPERINEAL RESECTION

Patient supine in the lithotomy positionAnus is closed with silk 0 sutureSterile field preparedLow midline incision carried down to peritoneumExploration of entire peritoneal cavityMobilization of the sigmoid and descending colon by incising the peritoneal reflection of the left paracolic gutterGonadal vessels separated and left ureter identifiedMobilization of distal part downward to the sacral promontory and the pre-sacral area dissection to the rectovesical space continuedIncision made at the right side of the sigmoid mesocolon down to rectovesical pouch and right ureter identifiedProximal sigmoid occluded with umbilical tapeLigation of inferior mesenteric artery, just after take-off form the aorta and inferior mesenteric vein

The lymphatic tissue in the pelvis removed with the specimen Sharp and blunt dissection of the rectum up to the level of the tip of the coccyxLateral stalks divided, and ligated with 2-0 silk suturesLines of resection identifiedSigmoid colon transected, both cut ends closed to prevent spillageColostomy site prepared

PERINEAL DISSECTION

Elliptical incision 3-4 cm anterior to the anal orifice and terminating at the tip of coccyxIncision carried into perirectal fatPerirectal fat incised down to the levator diaghragmAnococcygeal ligament cut with cauterySharp division of Waldeyers fasciaInferior and middle hemorrhoidal vessels ligated Levator muscles opened upward beginning from below up to the region of the puborectalis sling transected sigmoid specimen delivered through the perineal openingAnterior part of the perineal dissection carried outProstate gland / posterior vaginal wall can be included in the specimen if necessaryHemostasisWashing with NSSPerineum packed with gauze inside a gloveSkin closed with simple interrupted suturesColostomy matured to the skinHemostasisPeritoneum in the pelvic area closedPeritoneal washingComplete count Closure layer by layerPeritoneum and fascia vicryl 0 continuous interlocking suture

LICHTENSTEIN TENSION-FREE HERNIOPLASTY REXCISION OF LIPOMA OF CORD

Induction of spinal anesthesiaPatient supineAsepsis/antisepsisDrapings done leaving operative site exposedOblique incision done at R groinDissection carried down to subcutaneous, internal and external oblique aponeurosisBleeders checkedExposure and identification of vesselsMesh applied to wall defect, floor repairedClosure by layersSubcuticular stiches doneBetadine paintTop dressingEnd of procedure.

Varicocelectomy

(Modified Ivanissevich Approach)

Oblique inguinal incision over external inguinal ringExternal oblique aponeurosis dividedSpermatic cord isolatedInternal spermatic veins identified, isolated and ligated

(Suprainguinal Modified Palomo Approach)

Transverse incision 2 FB medial and FB (fingerbreaths) inferior to anterior superior iliac spine and continued medially

Retroperitoneum entered, internal spermatic vein, identified, isolated, and divided between ligatures

Location of incision, internal spermatic vein, identified on posterior aspect of peritnoneum, isolated, divided between ligatures.

Circumcision

Induction of spinal anesthesiaPatient positioned supine Oblique incision at R groin doneDissection carried down to subcutaneous, internal and external oblique aponeurosisFascia openedFloor repaired hemostasisClosure layer by layer oblique aponeurosis

- Subcuticular stichTop dressing doneEnd of procedure.

HEMORRHOIDECTOMY

Induction of spinal anesthesiaPatient placed in dorsal lithotomy position

Asepsis/antisepsisDrapings doneEvacuation of fecal materialDissection of hemorrhoidal pile from underlying sphincter musclesLigation of pedicle w/ slik sutureCutting of pedicleClosure by ______HemostasisBetadine paintInsertion of anal packTight top dressingEnd of procedure.

BELOW KNEE AMPUTATION

Patient supineAsepsis/antisepsisDrapings done leaving operative site exposedSkin, subcutaneous tissue, and superficial fascia incised sharply in chosen configurationMuscle bellies divided sharply/ electrocautery Neurovascular bundle doubly clamped, divided and ligated with excessive traction avoidedFibula divided 1cm proximal to the intended line of division of the tibia to form a conical shape to the stumpTibia divided perpendicular to its long axis with a hand or power bone sawPosterior flap madeAnterior aspect of tibia rounded and beveled to avoid bony prominence in the stumpWound irrigated with betadine washMuscles assessed for viabilityHemostasisSimple myodesis approximating the calf muscles over the bone endsSuperficial fascia sutured with interrupted absorbable suturesSkin approximated carefullyDog ears carefully tailoredSuture line covered with sterile dressingImmobilization using plaster splintEnd of procedure.

PARTIAL HIP REPLACEMENT-LEFT (AUSTIN-MORE PROSTHESIS 445MM) Induction of anesthesiaPatient positionedAsepsis/AntisepsisDrapings donePosterolateral skin incision with midpoint at the level of greater trochanterSharp dissection to joint capsuleExposure of capsule by opening the joint capsuleRemoval of necrotic and frayed soft tissuesRemoval of femoral headIrrigation with plain NSSSlight shortening of remaining femoral neckPiece-meal resection of boneReeming of the intramedullary canalInsertion of 45mm Austin-Moore prosthesisOpen reduction of acetabulumMuscles apposed and suturedSkin closure with vicryl 3-0 subcuticular stitchBetadine paintTop dressing doneEnd of procedure.

PARTIAL UNGEICTOMY

Patient positioned supineAsepsis/antisepsisDrapings done leaving the operative site exposedDigital block on base (location, R or L)Ingrone nail edge exposed, excisedGranulation tissue excisedNormal tissue and skin suturedBetadine paintDressing done End of procedure

EXCISION OF THYROGLOSSAL DUCT CYST(SISTRUNK PROCEDURE)

Patient positioned supineInduction of anesthesiaAsepsis/antisepsisTransverse incision done just above the cricoid cartilage transversing the cystIncision deepened exposing the hyoid bone and the cystCyst isolated from adjacent structureHyoid bone dissected ~1cm out to the chestDirect traced up to the base of the tongue, ligatedPlacement of drainClosure done up to the skinBetadine paintTop dressing doneEnd of procedure.