CVP INSERTION PD Cathetererization/ Tencknoff

Patient positioned supine Induction of anesthesia

Asepsis/Antisepsis Patient positioned supine
Drapings done Asepsis/Antisepsis
Infiltration of local anesthesia Drapings done
Incision done proximal to the cubital area done, deepened Skin incision done R parerectus 5cm from & below the umbilicus
Isolation of basilica vein done Incision deepened down to the peritoneum, muscles split
Veinotomy, cannulation with Fr. 8 feeding tube, patency checked Purse string sutures placed using vicryl 3-0
Distal portion of the vein ligated Peritoneum penetrated & Tencknoff catheter inserted catheter left intraperitoneally
Feeding tube anchored, three-way stop cock hooked and attached to mano Fascia & Rectus muscles approximated using vicryl 2-0 figure of 8
meter Skin closed w/ silk 4-0, simple mattress
Skin closure with silk 3/0 Betadine paint
Top dressing done Top dressings done
End of procedure. End of procedure.

I AND D SUTURING OF WOUND

IJ catheter insertion
Patient positioned supine
Asepsis/Antisepsis Patient positioned supine
Drapings done Asepsis/Antisepsis
Infiltration of local anesthesia Drapings done
Irrigation/debridement of lacerated wound (location) Infiltration of local anesthesia
Suturing of wound with nylon 4/0 Sildinger need inserted to the needle, needle removed leaving the guidewire
Betadine paint Dilator inserted, dilating internal jugular site and jugular vein
Top dressing done Jo-line inserted catheter inserted into the guidewire, guidewire removed
End of procedure. Patency checked, infiltration of heparin on catheter tip, locked
Catheter anchored with silk 3-0
Top dressing done
AVF CREATION End of procedure.

Patient positioned supine with L arm laterally extended

Asepsis/Antisepsis Pericardiostomy Tube Insertion
Drapings done
Infiltration of local anesthesia Induction of anesthesia
Incision done over forearm, deepened Patient positioned supine
Localization of radial artery, isolated Asepsis/Antisepsis
Vein ligated at distal portion, proximal portion approximated to the artery Drapings done
Arteriotomy done, then AV fistula created, using nylon 6/0 double arm Vertical incision done from the xiphisternal junction down to the tip the xiphoid
Bleeding checked, hemostasis, bruit checked and appreciated process
Closure of skin with nylon 6/0 - matress Blunt dissection is done to define the retrosternal plane
Top dressing done Pericardium approached extraperitoneally
End of procedure. Pericardium opened by a scalpel
Fluid control-sunctioned
Pericadiostomy tube inserted, exteriorized separate from incision site
Fistulotomy Tube attached to closed tube system
Closure
Induction of spinal anesthesia Tube secured with sutures
Patient placed in dorsal lithotomy position Top dressings with Povidine-Iodine and operative sponges
Asepsis/Antisepsis/Drapings End of procedure.
Anoscopy done
Erguson retractors applied
External openings probed and noted tract leading towards the anal mucosa
Feeding tube with peroxide solution inserted in the external opening to identify the External fixation
internal opening in the anal mucosa
Fistula probe inserted and tract identified, unroofed with cold and warm knife Patient positioned
External opening excised Wadding sheet applied from foot to proximal leg
Tract debrided with curette Plaster of Paris wet and applied in circular manner
Hemostasis Molded and allow to dry
Perieal mole excised End of procedure.
Palmar wart in the thumb of R hand cauterized
Top dressings with Povidine Iodine and Operative sponges
End of procedure.
Excision with Frozen Section Biopsy

CTT Patient positioned supine

Induction of anesthesia
Patient positioned Asepsis/Antisepsis
Identification of the 5th ICS in the Axillary line Drapings done exposing the incision area
Sterile prepand drapings done Incision done on RUQ
Infiltration of lidocaine anesthesia at a level below the pre-marked 5th ICS Excision of (size & char) mass on R breast
A horizontal skin incision done & deepened down to the subcutaneous fat with the Bleeders controlled, hemostasis done as controlled
kelly clamp a tract is created from the incision site superiorly posteriorly & Skin closure using _____
immediately above the superior edge of the 6 th ribs avoiding injury to the Betadine paint
neurovascular bundle Top dressing
Upon entering the pleural space, a gloved finger is placed through the tract into End of procedure.
the pleural space
Palpation to the lung to confirm pleural cavity location & assuring no adhesions are Tracheostomy Tube Insertion
present
Proximal end of the chest tube is grasped with a Kelly clamp and both inserted Patient positioned supine
through the subcutaneous tract into the pleural cavity directing the tube posteriorly Asepsis/Antisepsis
towards the apex Drapings done
Tube attached to water sealed bottle & securely anchored to the skin with silk Infiltration of local anesthesia
sutures Skin incision done horizontally over the 2 nd to 3rd tracheal ring
Vaselined gauze placed around the tube to seal Incision deepened down to the subcutaneous fat and platysma
Top dressings done muscle & exposing the sternohyoid muscles
End of procedure. Hemostasis
Elevation of the strap muscles done, making a vertical incision in the
CLOSE TUBE THORACOSTOMY R midline separating these two strap muscles
Incision was carried down to the upper trachea, exposing & dividing the
Patient positioned supine capsule of the thyroid gland
Asepsis/Antisepsis The isthmus as it crosses the trachea is retracted in the cephalad direction
Drapings done revealing the 2nd & 3rd tracheal ring
Induction of anesthesia Incision of the 2nd & 3rd tracheal ring done providing adequate
Incision done at R anterior auxillary line 6th ICS tracheostomy opening
Blunt dissection of the muscles up to the intercostals Cuffed endotracheal tube inserted into the tracheal incision, while the
Pleural puncture done endotracheal is extracted
Insertion of chest tube Fr 32 guided by the index finger, positioned in place Silk suture placed through the incision site on each side
Rubber tubing attached to the chest tube, initial straw-colored drain ~__cc, then Tracheostomy dressing done
attached to thoracostomy bottle End of procedure.
Tube anchored to skin with silk0skin closure with silk 3/0
Top dressing done
End of procedure.
 MRM
Induction of anesthesia VP Shunting
Patient positioned supine
Foley catheter insertion done Induction of anesthesia
Asepsis/Antisepsis Asepsis/antisepsis
Drapings done leaving the operative site exposed Drapings done leaving operative exposed
Stewart skin incision done, extending down perpendicular to the R parietal scalp incision done over the periosteum
Subcutaneous plane with 5-8 mm thickness Burr hole craniotomy done. Dura exposed and incised
Skin &subcutaneous flaps developed. Abdominal skin incision done over the R pararectus muscle 3 cm above the
Superiorly up to the subclavius muscle umbilicus
Inferiorly up to the caudal extension of the breast 2 cm inferior to the Incision deepened down to the peritoneum
inferior to the inframammary fold Shunt passer inserted subcutaneously from the scalp incision towards the
Medially up to the midline of the sternum abdominal incision
Laterally up to the anterior margin of the latissimus dorsi Ventriculoperitoneal shunt guided through the shunt passer and shunt passer
Bleeders clamped and ligated between sutures pulled out
Breast Tissue removed at the Pectoralis Major Fascia above the Shunt device anchored to the craniotomy, scalp closed with nylon 3-0
Pectoralis Musculature using the electrocautery and scalpel Peritoneal end of the shunt left inside the peritoneum
Perforator vessels clamped, ligated between silk sutures Peritoneum closed with vicryl 2-0
Breast & skin elevated pectoralis fascia from the lateral humeral extension to the Rectus muscles approximated with vicryl 3-0 using fig of 8
medial costochondrial junction, are elevated en bloc Rectus fascia closed with vicryl 3-0 using continuous running sutures
The lateral flap is elevated to the anterior margin of the latissimus dorsi
Skin closed with simple interrupted sutures using silk 3-0
Loose areolar tissue of the lateral axillary space elevated with identification of the
Betadine paint
lattermost extent of the maxillary vein
Top dressing
Dissection proceeds medially identifying the Long thoracic nerve & preserved;
End of procedure.
thoracodorsal nerve likewise identified & preserved
Entire breast & fascia are cleared medially & inferiorly from the aponeurosisof the
rectus abdominis muscle Left Hemicraniectomy
Operating field carefully inspected & bleeding points identified, clamped & ligated
Closed sunction drain left in place at the axilla & brought out to separate skin site Induction of anesthesia
Skin approximated with interrupted non-absorbable sutures, & Asepsis/antisepsis
subcutaneous w/ vicryl 4-0 Drapings done leaving operative site exposed
Betadine paint L parietal scalp incision done up to the periosteum
Top pressure dressing Bleeding controlled, hemostasis done as encountered
End of procedure. Holes borred through the cranium 2-3cm apart
Gigly wire guide passed through and wires passed,
Modified Neck Dissection, Thyroidectomy
Cranium cut through the giggly wire, done at entire span of Left cranium
Craniectomy done, dura exposed which is densed
Induction of general anesthesia
Hemostasis with surgical and electrocautery
Patient positioned with neck hyperextended
Exposed dura closed with apposition of aponeurosis
Asepsis/Antisepsis
Skin closure with nylon continuous mattress suture
Drapings done
Top dressing done
Incision deepeded to the areolar tissue plane just below the platysma
End of procedure.
Sharp dissection alternate with blunt dissection done to facilitate freeing of the
upper flap, isolation and excision of thyroid gland done
Dissection progressed with the exposure of thevsternocleidomastoid, the CRANIOTOMY CLIPPING ANEURYSM
dissection then shifted to the posterior cervical triangle, exposing
the borders of the trapezius muscles Patient supine
Lower flap produced, application of traction Induction of general anesthesia
Identification of the external jugular vein done and preserved, and Craniotomy prep done and drapings placed, secured with sutures
spinal accessory nerve identified and divided, dissection L fronto-parietal incision done, deepened, traversing skin, subcutaneous tissue,
carried down to the superior aspect of the clavicle dense connective tissue, epicranial aponeurosis, temporalis muscle loose
Common carotid artery exposed, dissection continued inferiorly and extended connective tissue, periosteum
superiorly, following the floor of the neck or the prevertebra fascia Clamps adequately placed, secured in groups with elastic bands
All loose areolar tissue about the caritod artery removed Periosteum seperated from calvaria
Superior dissection continued exposing the hypoglossal nerve, submental dissection Bleeders controlled as encountered
done. Traction of the maxillary gland done to expose lingual nerve, Burr hole made on points for otomy, dura left intact separated from inner table by
salivary duct and hypoglossal nerve. dissector and wire guide, proceeded with Gigly wire cutting, calved separated
Anterior belly of the omohyoid muscle is divided from the sling of the digastric from dura
muscle. Dissection completed after the posterior belly of the digastric muscle is Protruding portions Rougeured off
exposed Leyla retractors applied, secured
Retraction of the posterior belly of the digastric superiorly exposed the internal Dissection done up to the level of the optic chiasm
jugular vein, vein clamped and divided. Anterior circulation of the Circle of Willis identified
Internal jugular vein clamped high, dissection completed with the division of the Anterior communicating artery identified, aneurysm located
sternocleidomastoid in the mastoid process. Aneurysm clipped with permanent clips, wrapped with crayanoacrylate coat
Bleeders clamped and ligated cellulose fiber
Hemostasis done, washing Profuse irrigation
Platysma approximated and closed Hemostasis
Release of skin traction and closure done Duraplasty with vicryl 3-0
Drain applied and left in place Insertion of JP drain, exteriorized separate from incision site, secured with sutures
Skin closure via subcuticular stitch Calvria replaced
Top dressing done Closure of scalp
End of procedure. Connective tissue, aponeurosis using vicryl 3-0 simple interrupted
Skin, subcutaneously using nylon 3-0 vertical mattress
TOTAL THYROIDECTOMY
Betadine paint
Top dressing done with OS
Induction of general anesthesia End of procedure
Patient positioned with neck hyperextended
Asepsis/Antisepsis/Drapings
Incision done dividing the skin and subcutaneous tissue
Appendectomy Drop Method via Rocky Davis Incision
Incision deepened to the areolar tissue plane just below the platysma
Sharp dissection alternate with blunt dissection done to facilitate freeing of upper
Induction of spinal anesthesia
flap
Patient supine
Dissection reaching the thyroid notch, exposing the entire thyroid cartilage and
Asepsis/Antisepsis
downward to the suprasternal notch
Drapings done
Lower flap produced, application of traction
Transverse incision done at McBurney,s point (Rocky-Davis Incision)
Plane of cleavage between the sternocleidomastoid muscle and the outer
Incision deepened, traversing the skin, subQ, transversalis fascia, muscles and
boundaries of the sternohyoid muscle
peritoneum
Plane develop with sharp and blunt dissection between the thyroid gland and
Hemostasis
sternohyoid muscle
Appendix isolated
Bleeders clamped and ligated
Appendiceal artery identified, clamped, cut, ligated with silk 3-0
Release of thyroid gland at the superior pole by blunt dissection
Appendix base clamped, cut and secured with use of purse string stitch using silk 3-
Vessels preserved, identification of the recurrent laryngeal nerve done and
0
preserved
External oblique with chromic 3-0
Release of thyroid gland at the middle and inferior pole done, identify the middle
Fascial closure
and inferior thyroid vessels
Skin closure with nylon 3-0
Isthmus identified and released
Wound painted with povidine iodine
Same procedure done at the contra-lateral thyroid lobe
Top dressing done
Release of the entire thyroid gland done
Specimen for histopathology
Hemostasis done, washing
End of procedure.
Release of skin traction and closure done
Drain applied and left in place
Skin closure with vicryl 4/0 – subcuticular stitch
Top dressing done
Specimen for histopathology
End of procedure.
 Appendectomy - Ruptured Pyelolithotomy

Induction of anesthesia Induction of anesthesia

Foley catheter insertion done Patient placed in the standard flank position, table is broken, and tapes are placed
Asepsis/antisepsis to secure the patient
Drapings done leaving operative site exposed Asepsis/antisepsis
Rocky-Davis skin incision done over the R lower quadrant Drapings done
Skin incision deepened down to the peritoneum Subcostal incision is done started at the lateral border of the sacrospinalis muscle 1
Retractors applied. Appendix identified and isolated cm below the lower edge of the 12th rib and follow the lower border of the rib
See above intra op findings anteriorly, ending at the lateral border of the rectus muscle
Appendectomy done – Drop Method Incision deepened through subQ, fascia down to the latissimus dorsi muscle and
Hemostasis serratus posterior inferior muscles from their anterior free borders, then the external
Drain, penrose left at the R gutter & brought out through a separate incision and interior oblique at their posterior free borders
Closure done layer by layer Lumbosacral fascia identified, sharply incised well posteriorly, transversalis muscle
Peritoneum closed with vicryl 1-0, continuous running sutures then identified, incised and split, exposing the peritoneum and pushed anteriorly
Muscles approximated w/ vicryl 1-0 continuous interlocking sutures Posterior layer of the lumbosacral fascia is then incised from the anterior border of
Skin closed w/ vicryl 4-0 subcutaneously the sacrospinalis muscle
Betadine paint Retractors applied
Top dressing Perirenal fat is then separated from the underlying pelvic area of the kidney, and
End of procedure. the posterior surface id gently exposed
Upper ureter is identified and an identi-loop is wrapped around it, and connection
Craniotomy, Evacuation Hematoma with the pelvis in the renal sinus is traced
Pelvis is incised open, and the lithiasis is extracted in oto
Induction of anesthesia Flushing of the pelvocalyceal system done to expect remaining lithiasis
Aspesis/Antisepsis Hemostasis
Drapings done leaving the operative site exposed Renal pelvis is repaired via continuous stich using chromic 4-0 sutures
L parietal scalp incision done up to the periosteum Closed suction drain is placed around the pelvis and exteriorized separate from the
Craniotomy done, Dura mater exposed and incised incision site, tube secured to the skin with sutures
Evacuation of blood/ blood clots done Table is then broken to further coaptation of tissue edges
Flushing in dural space with catheter until return flow is clear Closure layer by layer
Dura repaired, scalp closed with vicryl 3-0 Lumbodorsal fascia prolene 0 continuous
Skin closure with nylon continuous mattress suture Internal and external oblique vicryl 0 continuous
Top dressing done Lastissimus dorsi, serratus posterior vicryl 0 continuous
End of procedure. SubQ plain 2-0 simple interrupted
Skin vicryl 3-0 subcuticular
Craniotomy Tube Ventriculostomy Top dressing with Povidine iodine and operative sponges
End of procedure.
Patient supine
Induction of general anesthesia EXLAP
Craniotomy prep done and drapings placed, secured with sutures
Previous incision site of (L) ventriculostomy entered Patient positioned supine
Ventriculostomy tube removed, needle inserted to assess flow of CSF Asepsis/antisepsis
Insertion of new tube done and attached to a collecting bag Drapings done
Profuse irrigation Abdominal midline sutures removed up to the peritoneum
Hemostasis Abdomen explored, previous anastomotic site intact with no peri-anastomotic fluid
Closure of scalp using silk 3-0 full thickness via Horizontal mattress collection
Top dressing with povidine iodine and OS Dilated afferent loop from the previous gastro-jejunostomy and adjacent jejunum
End of procedure. sutured together with anchor sutures of silk 3-0
Jejuno-jejunostomy done with silk 4-0 sero-muscular layer sutured simple interrupted
and vicryl 4-0 mucosal layer sutured via Gambee technique
ORT VP shunting
Adhesiolysis
Lavage done
Induction of Anesthesia
Tube jejunostomy attachment to peritoneal wall secured
Asepsis/ Antisepsis
NGT (Fr 18 feeding tube) inserted and threaded to bypass the anastomosis
Drapings done leaving operative site exposed
Hemostasis
R Parietal scalp incision done to the periosteum
Insertion of passive (Penrose) drain and placed on the anastomotic sites,
Burr hole craniotomy done. Dura exposed and incised
exteriorized separate from the incision site
Abdominal skin incision done over the R pararectus muscle
Closure
3 cm above the umbilicus
Peritoneum rectus sheath using Prolene 0 continuous external retention sutures
Incision deepened down to the peritoneum
Fascia using Prolene 0 simple with bumpers
Shunt passer inserted subcutaneously from the scalp incision
Skin using silk 3-0 vertical mattress
towards the abdominal incision
Top dressing with Povidine iodine and operative sponges
Ventriculoperitoneal shunt guided through the shunt passer and
End of procedure.
shunt passer pulled out
Shunt device anchored to the craniotomy, scalp closed w/ nylon 3-0
Peritoneal end of the shunt left inside the peritoneum Laparoscopic Cholecystectomy
Peritoneum closed with vicryl 2-0
Rectus muscles approximated w/ vicryl 3-0 using fig of 8 Patient positioned supine
Rectus fascia closed w/ vicryl 3-0 using continuous running sutures Asepsis/ antisepsis
Skin closed withsimple interrupted sutures using silk 3-0 Drapings done
Betadine paint Incision is made in the umbilicus and dissected up to the level of the
Top dressing peritoneum and opened
End of procedure. Hasson 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
Nephrectomy
Abdomen explored
Additional ports are then placed under direct vision; a 10mm port is placed in
Induction of anesthesia epigastrium, and another 5 mm port in the midclavicular line, right
Patient on L/R lateral decubitus position Thigh the lateral port, the gallbladder fundus was grasped and the hepatocystic
Asepsis/antisepsis triangle is identified and dissected
Drapings done leaving operative site exposed Incisions freed using electrocautery
L/R lumbar incision, deepened Cystic artery was identified and 2 proximal and 1 distal clips were applied
Lumbosacral fascia opened cystic artery was then cut
Kidney isolated from the perinephric fat Cystic duct was identified and 2 proximal and 1 distal clips were applied,
Renal artery identified, clamped, cut, and ligated cystic duct cut
Hemostasis Gallbladder freed from the liver bed using blunt and hot dissection
Drain placed Hemostasis
Closure (lumbodorsal fascia/sub cutaneous skin) Gallbladder was then delivered through the epigastric port
Top dressing done Closure of wound was then done using vicryl 2-0 on the fascia and
End of procedure. nylon 3-0 subcuticular stitch on the skin
Top dressing with Povidine iodine and oprative sponges
End of procedure.
 Lap converted to Open Cholecystectomy Puff Through

Patient positioned supine Patient positioned supine

Induction of general anesthesia Induction of general anesthesia
Asepsis/ antisepsis Asepsis/ antisepsis
Drapings done Drapings done
An incision is made in the umbilicus and dissected up to the level of the Dilators serialty inserted up to maximum allowable size
peritoneum and opened Inscision made just above the dentate line, freeing the mucosal layer from
A Hasson’s cannula is then inserted and carbon dioxide is insufflated and adequate underlying muscle layer
pneumoperitoneum Mucosa fixed accordingly while circumferentially freeing the mucosa
Is establish, fixed, laparoscopic with the attached video camera is passes through Portion of muscularis sent for frozen section biopsy
the umbilical part Mucosal tube dissected down to the perineum
Abdomen explored Mucosa is freed from submuscusal layer
2 additional ports are then placed under direct vision, a 10mm port is placed Bleeders controlled as encountered
the epigrastrium, and another 5 mm port in the midclavicular line, right Incision extending down to the level of colon
Through the lateral port, the gallbladder fundus was grasped and the hepatocystic Biopsy done
triangle is identified and dissected Transition zone noted and dissected futher proximally just about the
Cystic artery was identified and 2 proximal and 1 distal clips were applied same length as the mucosal tube
Cystic artery was then cut Portion of ganglionic segment of colon fixed to seromuscular cuff as it is
An aberrant vessel was then noted, after transecting the artery, and this produced circumferentially up to the adequate level of colon
brisk bleeding in the operative field, the bleeder was identified but End to end anastomotic done of pulled through segment of colon and the mucosal
there was difficulty in clamping due to the pooling of blood and layer of the rectumat the level of thedentate line with interrupted stitch
inadequacy of the suction to clear the hepatocystic triangle is Top dressing with Povidine Iodine and operative sponges
identified End of procedure.
Laparoscopic surgery aborted
R subcostal Kocher’s incision is then made, traversing skin subcutaneous tissue, Transverse Loop Colostomy
anterior rectus sheath
Rectus muscle cut with electrocautery, and posterior rectus sheath, Patient positioned supine
pre-peritoneal fat, peritnoneum opened Induction of general anesthesia
Gallbladder and hepatoduodenal ligament exposed alier retractors were Asepsis/ antisepsis
placed and the GB fundus was lifted up Drapings done
Betadine paint RUO incision, transverse
Top dressing A knuckle of transeverse colon was delivered into the wound, omentum
End of procedure. retracted upward
Cholecystectomy Omentum is divided over the presenting portion of the transeverse colon,
reflected to either side
Patient positioned supine Insertion of rubber catheter
Induction of general anesthesia Rubber catheter tip is cut off and one end inserted into the other point
Foley catheter insertion done Fat tabs on the loop of bowel were anchored to adjacent peritoneum
Asepsis/ antisepsis Peritoneal opening was partially closed by interrupted sutures
Drapings done leaving operative site exposed Skin and SubQ closed
Transverse oblique, skin incision done over R subcostal area Placement of colostomy bag
Skin incision deepened exposing the gallbladder Dressing done
Pls see above intra op findings End of procedure.
Hepatoduodenal peritoneum excise exposed & isolating the LOW ANTERIOR RESECTION, STAPLED ANASTOMOSIS AND DIVERTING
cystic duct & Cystic artery ILEOSTOMY
Cystic artery divided between 2 silk ligatures Induction of anesthesia
Cystic duct isolated, divided between 2 silk ligatures Asepsis/Antisepsis
Gallbladder dissected form the liver bed, hemostasis Drapings done leaving operative site exposed
Washing with PNSS & suctioned out hemostasis Midline skin incision done 2cm above the umbilicus extending done
Peritoneum and posterior rectus approximated w/ vicryl 1, continuous running to the suprapubic area
sutures Incision deepened to the peritoneum
Anterior rectus fascia approximated w/ vicryl 1, continuous interlocking sutures Retractors applied (see intra-op findings)
Fascia closed w/ plain 2-0 figure of 8 suturing Sigmoid & transverse colon mobilized small bowels walled off and
Skin closed w/ vicryl 4-0 subcutaneously self-retaining retractors applied
Betadine paint Peritoneum of the pelvic colon is freed form region of the sigmoid down
Top dressing done to the other side
End of procedure Peritoneum divided anteriorly to the rectum at the level of the base of the other
Chole, IOC, CBDE, T-Tube side
Peritoneum further mobilized and surgeon passes R hands posteriorly
Patient positioned supine do to the hollow of the sacrum
Induction of general anesthesia Rectum freed posteriorly and anteriorly by blunt finger dissection
Asepsis/ antisepsis Blood supply to the distal segment of the inferior hemorrhoidal vessels &
Drapings done inferior mesenteric artery ligated
Midline incision done Anastomosis clamped, applied below gross lower limits of the mass &
Skin incision deepened up to the peritoneum another clamp applied across previously prepared site proxima
Retractors applied exposing the gallbladder and the anti-mesenteric l to the mass
border of the bowel Bowel divided between clamps
Longitudinal incision of the fundus of the gallbladder the anti-mesenteric Lateral peritoneal attachment further divided from the left colon up to
boerder of the bowel transverse colon freeing the splenic flexure
Anastomosis of the fundus of the gallbladder and anti-mesenteric border of the Absorbable traction suture placed to serve as stay suture to the end of the
bowel sutured in place using Conell suture rectum and pursestring suture placed to closed end of the rectum
Isolated jejunum, anchored to the gastric wall of the fundus and sutured Pursestring suture tied snuggly around shaft of open stapler
Incision at the posterior gastric wall and proximal portion of the jejunum Another pursestring suture applied at the end of the proximal sigmoid by
Anastomosis of the proximal portion of the jejunum and the posterior portion of the same technique used for rectal stump
gastric wall and sutured in placing using Conell suture Open end of the sigmoid gently manipulated over the end of the anvil
Wedge biopsy of the pancreatic body tumor done Assistant tightens clamp form below and surgeon form above prevents
Ligation of blood vessels fatty tissues form being trapped between lower ends
Washing Assistant verifies if stapler is tightened to the correct thickness for height
Closure
Top dressing ABDOMINOPERINEAL RESECTION
End of procedure.
Patient supine in the lithotomy position
Anus is closed with silk 0 suture
Sterile field prepared
Low midline incision carried down to peritoneum
Exploration of entire peritoneal cavity
Mobilization of the sigmoid and descending colon by incising the peritoneal
reflection of the left paracolic gutter
Gonadal vessels separated and left ureter identified
Mobilization of distal part downward to the sacral promontory and the pre-sacral
area dissection to the rectovesical space continued
Incision made at the right side of the sigmoid mesocolon down to rectovesical
pouch and right ureter identified
Proximal sigmoid occluded with umbilical tape
Ligation 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 coccyx
Lateral stalks divided, and ligated with 2-0 silk sutures
Lines of resection identified
Sigmoid colon transected, both cut ends closed to prevent spillage
Colostomy site prepared
 PERINEAL DISSECTION BELOW KNEE AMPUTATION

Elliptical incision 3-4 cm anterior to the anal orifice and terminating at the tip of Patient supine
coccyx Asepsis/antisepsis
Incision carried into perirectal fat Drapings done leaving operative site exposed
Perirectal fat incised down to the levator diaghragm Skin, subcutaneous tissue, and superficial fascia incised sharply in chosen
Anococcygeal ligament cut with cautery configuration
Sharp division of Waldeyer’s fascia Muscle bellies divided sharply/ electrocautery
Inferior and middle hemorrhoidal vessels ligated Neurovascular bundle doubly clamped, divided and ligated with excessive traction
Levator muscles opened upward beginning from below up to the region of the avoided
puborectalis sling transected sigmoid specimen delivered through the perineal Fibula divided 1cm proximal to the intended line of division of the tibia to form a
opening conical shape to the stump
Anterior part of the perineal dissection carried out Tibia divided perpendicular to its long axis with a hand or power bone saw
Prostate gland / posterior vaginal wall can be included in the specimen if Posterior flap made
necessary Anterior aspect of tibia rounded and beveled to avoid bony prominence in the
Hemostasis stump
Washing with NSS Wound irrigated with betadine wash
Perineum packed with gauze inside a glove Muscles assessed for viability
Skin closed with simple interrupted sutures Hemostasis
Colostomy matured to the skin Simple myodesis approximating the calf muscles over the bone ends
Hemostasis Superficial fascia sutured with interrupted absorbable sutures
Peritoneum in the pelvic area closed Skin approximated carefully
Peritoneal washing Dog ears carefully tailored
Complete count Suture line covered with sterile dressing
Closure layer by layer Immobilization using plaster splint
Peritoneum and fascia – vicryl 0 continuous interlocking suture End of procedure.

LICHTENSTEIN TENSION-FREE HERNIOPLASTY R

EXCISION OF LIPOMA OF CORD

Induction of spinal anesthesia PARTIAL HIP REPLACEMENT-LEFT (AUSTIN-MORE PROSTHESIS 445MM)

Patient supine
Asepsis/antisepsis Induction of anesthesia
Drapings done leaving operative site exposed Patient positioned
Oblique incision done at R groin Asepsis/Antisepsis
Dissection carried down to subcutaneous, internal and external oblique Drapings done
aponeurosis Posterolateral skin incision with midpoint at the level of greater trochanter
Bleeders checked Sharp dissection to joint capsule
Exposure and identification of vessels Exposure of capsule by opening the joint capsule
Mesh applied to wall defect, floor repaired Removal of necrotic and frayed soft tissues
Closure by layers Removal of femoral head
Subcuticular stiches done Irrigation with plain NSS
Betadine paint Slight shortening of remaining femoral neck
Top dressing Piece-meal resection of bone
End of procedure. Reeming of the intramedullary canal
Varicocelectomy Insertion of 45mm Austin-Moore prosthesis
Open reduction of acetabulum
(Modified Ivanissevich Approach) Muscles apposed and sutured
Skin closure with vicryl 3-0 – subcuticular stitch
Oblique inguinal incision over external inguinal ring Betadine paint
External oblique aponeurosis divided Top dressing done
Spermatic cord isolated End of procedure.
Internal spermatic veins identified, isolated and ligated

(Suprainguinal Modified Palomo Approach)

Transverse incision 2 FB medial and FB (fingerbreaths) inferior to anterior superior iliac PARTIAL UNGEICTOMY
spine and continued medially
Retroperitoneum entered, internal spermatic vein, identified, isolated, and divided Patient positioned supine
between ligatures Asepsis/antisepsis
Location of incision, internal spermatic vein, identified on posterior aspect of Drapings done leaving the operative site exposed
peritnoneum, isolated, divided between ligatures. Digital block on base (location, R or L)
Ingrone nail edge exposed, excised
Granulation tissue excised
Circumcision Normal tissue and skin sutured
Betadine paint
Induction of spinal anesthesia Dressing done
Patient positioned supine End of procedure
Oblique incision at R groin done
Dissection carried down to subcutaneous, internal and external oblique
aponeurosis
Fascia opened
Floor repaired hemostasis
Closure layer by layer – oblique aponeurosis
- Subcuticular stich EXCISION OF THYROGLOSSAL DUCT CYST
Top dressing done (SISTRUNK PROCEDURE)
End of procedure.
Patient positioned supine
Induction of anesthesia
Asepsis/antisepsis
HEMORRHOIDECTOMY Transverse incision done just above the cricoid cartilage transversing the cyst
Incision deepened exposing the hyoid bone and the cyst
Induction of spinal anesthesia Cyst isolated from adjacent structure
Patient placed in dorsal lithotomy position Hyoid bone dissected ~1cm out to the chest
Asepsis/antisepsis Direct traced up to the base of the tongue, ligated
Drapings done Placement of drain
Evacuation of fecal material Closure done up to the skin
Dissection of hemorrhoidal pile from underlying sphincter muscles Betadine paint
Ligation of pedicle w/ slik suture Top dressing done
Cutting of pedicle End of procedure.
Closure by ______
Hemostasis
Betadine paint
Insertion of anal pack
Tight top dressing
End of procedure.