Oxford Handbook of Clinical Surgery (4 edn)
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Diagnostic laparoscopy 730
Principles of laparotomy 732
Cholecystectomy 734
Appendicectomy 736
Inguinal hernia repair 738
Perforated peptic ulcer repair 740
Haemorrhoid surgery 742
Pilonidal sinus excision (Bascom II) 744
Femoral embolectomy 746
Right hemicolectomy 748
Stoma formation 750
Wide local excision—breast 752
Below knee amputation 754
Diagnostic laparoscopy
Indications (typical)
Acute/emergency
Elective
Investigation of subfertility.
Investigation of chronic abdominal pain.
To perform biopsy (e.g. omental or lymph node) in suspected malignancy.
Pre-theatre preparation
Always GA, therefore NBM 2h and fluids only 4h preop.
Group and save required.
Ensure consent is obtained for proceeding to other procedures if they are anticipated.
Positioning and theatre set-up
Urethral catheterization. Usual, especially if lower abdominal pathology/assessment likely, to ensure the bladder is decompressed.
NGT. NOT required unless the patient is vomiting or gastric distension/surgery is likely.
Table positioning. Supine. It is always best to have the patient in leg extensions. They allow the perineum to be accessed if vaginal manipulation or lower GI endoscopy is needed and they help to secure the patient on the table if head downtilt or lateral role is required.
Monitor/stack position. Depends on the expected pathology.
Steps of surgery
Incision. Periumbilical; usually curved infra-umbilical although supra-umbilical is also used. Vertical infra-umbilical can be used, especially where conversion to a midline laparotomy is anticipated.
Exposure of the linea alba. By sharp dissection.
Incision of linea alba. Elevate with forceps and incision with scalpel (no. 11 or 15).
Open trochar insertion. Elevate linea alba with forceps, blunt scissor opening of pre-umbilical fat pad and peritoneum and placement of trochar (blunt) or:
Blunt trochar insertion. Elevate linea alba with forceps without a small initial incision, insert trochar (blunt or with visual assistance using laparoscope inside the port) or:
Verres needle insertion. Elevate linea alba with forceps, insert Verres needle using only thumb and finger pressure until ‘clink’ felt, test for intraperitoneal placement with saline ‘drop’ test.
Insufflation. CO2 typical pressure between 12–15mmHg; use slow flow initially, check for low pressure flow before increasing flow rate.
Assessment. Inspect area beneath insertion port for signs of visceral injury or bleeding, assess anterior abdominal wall for availability of further port sites, inspect viscera sequentially.
Closure
Port sites 10mm and above require musculofascial closure, 5mm ports do not.
Post-operative care and instructions
Remove catheter unless required for post-operative fluid balance observation.
Antibiotics. Only required for pathology found.
Oral diet. Normal as soon as tolerated.
Complications (specific to the procedure)
Port site infection, <5%.
Port site herniation, <2% if closed.
Visceral injury during port insertion/basic laparoscopy and assessment, <1%.
Principles of laparotomy
Laparotomy is the term for any open access to the peritoneal cavity and includes midline incisions as well as paramedian and oblique approaches. It is the traditional method of access for most visceral surgery. It is still the approach of choice for some trauma, many emergency presentations, and some extensive surgery.
Pre-theatre preparation
All, but smaller lower abdominal incisions which may be performed under regional or field block LA, require GA.
Group and save or cross-match, depending on procedure.
Ensure consent is obtained for other procedures if anticipated.
Positioning and theatre set-up
Urethral catheterization. Usual, especially if lower abdominal pathology/assessment likely, to ensure the bladder is decompressed.
NGT. Usual for upper intestinal obstruction (to reduce risk of aspiration at induction).
Table positioning. Several are possible (see 
p. 76).
Supine. Most common for open visceral surgery (e.g. small and large bowel, gastric and major arterial).
Lloyd Davis (supine with hips slightly flexed and abducted). Used where access is required to the peritoneal cavity and the perineum/anorectum.
Lateral. For combined approaches to the retroperitoneal structures.
Steps of surgery
Skin incision. Scalpel or cutting diathermy with needle point electrode.
Fat incision. Blend diathermy to reduce risk of bleeding.
Midline access (see p. 82)
Midline fascia (linea alba) incision. At or above the umbilicus (pre-peritoneal fat reduces the risk of underlying bowel injury). The midline can be identified by the presence of oblique crossing/interleaved fascial fibres. Expose fascia, elevated with clips to generate negative intra-abdominal pressure and sharply incised.
Access extension. With blend diathermy in the midline.
Paramedian access
Rectus sheath fascia incision. Vertical with blend diathermy.
Rectus muscle. Fibres separated with minimum muscle division.
Peritoneal incision. Elevated between clips and sharply incised.
Access extension. With blend diathermy vertically.
Oblique access (e.g. gridiron, subcostal)
Rectus sheath fascia incision. Oblique with blend diathermy.
Muscle. For small incisions, fibre separation may achieve adequate access; this may be multiple layers (e.g. gridiron) or single (e.g. mini-subcostal). For larger incisions, muscle division with coagulation diathermy is required (e.g. full subcostal).
Basic procedures
Assessment of ‘non-target’ viscera. Traditionally performed, but less important with preoperative imaging (especially CT scanning). Done in logical progression, e.g. central (small bowel, omentum, transverse colon), left upper quadrant (LUQ) (spleen, stomach), right upper quadrant (RUQ) (liver, gall bladder), right flank (right colon, right kidney), pelvis (bladder, uterus, ovaries, rectum), left flank (left colon/kidney).
Assessment of ‘target’ organ(s). Depends on pathology expected, but consider these issues—‘resectability’ (tethering/involvement of vital, non-resectable structures), extent of resection (length or additional organs/structures to remove), mobility (adequate approximation of structures to be joined).
Specimens
Ascites (free fluid). Send for M,C,&S; send for cytology if suspected malignancy.
Pus. Send for M,C,&S (as liquid specimen if possible) or swab.
Peritoneal tissue. Excise or biopsy peritoneal tissue nodules (parietal or visceral).
Key principles of emergency laparotomy
Bleeding. Control by pressure (packs) initially rather than direct closure (clips or sutures); remove packs, starting with those least likely to cover bleeding sites; allow anaesthetic ‘catch up time’.
Multiple visceral injuries. ‘Close and control’ rather than ‘restore and join’. Preventing contamination and visceral leakage are required, but restoration of anatomy/physiology can be deferred to subsequent procedures.
Contamination. Seek out and treat all areas of pus/contamination. Frequently overlooked areas are subphrenic, subhepatic, interloop ileal, pelvic. Wash should be warm, copious, and repeated sequential dilutions rather than a single large washout. Large calibre drains for heavily soiled areas (likely to recollect), consider repeat (‘re-look’) surgery in 24–48h.
Closure
Peritoneum. Should be approximated where possible (reduces risk of adhesions to exposed muscle) with absorbable suture; may be included with musculo-fascial closure (e.g. mass closure).
Muscle fibres. Where parted—will usually re-approximate without sutured closure; where slit—may require absorbable sutures.
Fascia. Always closed, usually heavy absorbable sutures, but may be non-absorbable.
Skin. Sutures (subcuticular or interrupted) or clips.
Complications (specific to the procedure)
Wound infection, 2–30%, depending on pathology.
Incisional hernia, up to 30%; affected by sepsis, malnutrition, age.
Cholecystectomy
Simple cholecystectomy (removal of gall bladder and proximal cystic duct) is restricted to benign disease.
Open approach (elective) is usually only indicated for common bile duct exploration where laparoscopic exploration is not possible.
Indications (typical)
Symptomatic proven gallstones.
Symptomatic congenital abnormalities of the gall bladder.
Previous acalculous cholecystitis.
Very rarely indicated for prophylaxis in individuals at risk of cholecystitis (congenital heart disease, immunosuppressed).
Pre-theatre preparation
Always GA, therefore NBM 2 h and fluids only 4h preop.
Group and save required.
Ensure consent is obtained for proceeding to other procedures if they are anticipated (e.g. common bile duct exploration).
Check LFTs and any previous ERCP/MRCP imaging has been reviewed.
Positioning and theatre set-up
Urethral catheterization; NGT NOT required.
Table positioning. Supine. Some surgeons prefer to stand between the legs for the dissection (requires the patient in leg extensions).
Monitor/stack position. LUQ.
Patient may be placed slightly head up and left side down to improve RUQ exposure.
Steps of surgery
Establish laparoscopy (see p. 730) if appropriate.
Incision for open surgery. Right subcostal (‘Kocher's’) with (partial) division of upper right rectus muscle.
Expose gall bladder neck, cystic duct and common bile duct (‘Calot's triangle)—fundal traction. Tip: if exposure is poor, try adding further 5mm ports for retraction and ask for another assistant.
Identify cystic duct origin from gall bladder neck by blunt dissection.
Identify cystic artery by blunt dissection.
Clip (or tie if open) cystic duct (2 distal, 1 or 2 proximal on gall bladder neck) and divided. Repeat for cystic artery.
Dissect gall bladder from liver ‘bed’ by retrograde dissection (i.e. from neck to fundus). Dissection is carried out close to the gall bladder wall.
Gall bladder retrieved (usually in a waterproof bag if laparoscopic via epigastric port).
Check haemostasis.
Closure
(a) Ports sites for laparoscopic cholecystectomy. (b) View of Calot's triangle after dissection prior to structure division. (Borders: LS, liver surface; CHD, common hepatic duct; CD cystic duct. Other structures: GB, gall bladder; CBD, common bile duct; CA, cystic artery.)
Post-operative care and instructions
Remove catheter unless required for post-operative fluid balance observation.
Antibiotics. Only required for pathology found (e.g. cholecystitis).
Oral diet. Normal as soon as tolerated.
Complications (specific to the procedure)
Port site infection, <5%.
Bleeding, 2%.
Conversion to open surgery (if laparoscopic), 2% (depends on gender, age, sex, previous inflammatory episodes, previous abdominal surgery).
Visceral injury during port insertion/basic laparoscopy and assessment, 1%.
Common bile duct injury, 1 in 300.
Appendicectomy
Most surgeons prefer the laparoscopic approach for suspected or proven appendiceal pathology. Open right iliac fossa (RIF) incisions offer less exposure with greater tissue trauma. Consider a lower midline laparotomy if there is a large appendix mass, the patient is elderly, and other pathology is suspected.
Indications (typical)
Acute appendicitis (see p. 298).
Acute abdominal pain where diagnostic laparoscopy has revealed no other cause (not always performed).
Previous resolved appendicitis (‘interval appendicectomy’).
Appendix mass or mucocele (usually discovered on CT imaging).
Pre-theatre preparation
Always GA, therefore NBM 2h and fluids only 4h preop.
Group and save normal.
Check the CT imaging if one has been performed.
Positioning and theatre set-up
Urethral catheterization. Aids port placement safety, especially in females, by ensuring the bladder is decompressed.
Table positioning. Supine; it is always best to have the patient in leg extensions (see p. 76).
Monitor/stack position. Right caudal.
Steps of surgery
Establish laparoscopy (see p. 730) if appropriate.
Incision for open surgery, RIF oblique (‘gridiron’). Incision of skin, open external oblique, internal oblique, and transversus abdominis, splitting the fibres in the direction of their travel without cutting them. Open the peritoneum between clips.
Identify appendix from the base attachment to the caecum (the base lies reliably on the inferomedial pole of the caecum at the confluence of the taenia coli, the tip is variable in position).
Mobilize the appendix from all surrounding structures, if necessary, by blunt dissection.
Open the appendix mesentery from tip towards the caecum by diathermy (hook if laparoscopic).
Identify appendiceal artery by blunt dissection and clip (or tie if open) (2 proximal, 1 distal on appendix side) and divide.
Complete mesenteric division to appendiceal-caecal angle.
Doubly ligate appendix stump close to caecum (with Endoloop® if laparoscopic) and divide between.
Appendix retrieved (usually in a waterproof bag if laparoscopic via umbilical port to reduce wound infection risk).
The appendix stump is now rarely buried with a purse-string suture at open appendicectomy; there is no evidence that it reduces stump complications.
Closure
(a) Port sites for laparoscopic appendicectomy—main ports sites in black; alternative layout for 2 x 5mm port sites in white. Monitor usually right side, caudal. (b) View of appendix and mesentery prior to dissection/division. (App, appendix; AM, appendix mesentery; AppArt, appendiceal artery; Cae, caecum; AMF, antemesenteric fat of terminal ileum; TI, terminal ileum.)
Post-operative care and instructions
Antibiotics. Five-day course if acute appendicitis with perforation.
Oral diet. Normal as soon as tolerated.
Complications (specific to the procedure)
Wound/port site infection, <5% (greater if open and perforated).
Inguinal hernia repair
Open approach is still very popular, especially for LA/regional anaesthetics, but laparoscopic approaches (transabdominal pre-peritoneal surgery (TAPS) or totally extra-peritoneal surgery (TEPS) are also widely used, especially for bilateral hernias (see p. 338).
Indications (typical)
Symptomatic inguinal hernia.
Asymptomatic inguinal hernia with high risk of complications or patient at high risk if complications develop.
Pre-theatre preparation
May be GA, LA (± sedation), or regional block (e.g. spinal).
Positioning and theatre set-up
Urethral catheterization. NOT usually required for open unless the patient is at high risk of acute retention, but used for TEPS/TAPS.
Table positioning. Supine.
Monitor/stack position (TAPS/TEPS). Caudal end, same side as hernia.
Steps of surgery
Open
Identify external oblique aponeurosis and cord at the superficial ring.
Open aponeurosis, identify cord and deep ring.
Direct hernia. Separate cord from sac, reduce sac, and plicate transversalis fascia to hold sac reduced.
Indirect hernia. Open cord, separate sac from cord structures, sac may be reduced and the deep ring plicated or sac ligated and excised at the deep ring.
Polypropylene mesh placed to cover from pubic tubercle to lateral to the deep ring; usually sutured in place.
Laparoscopic TAPS
Establish laparoscopy (see p. 730).
Open parietal peritoneum above hernia (e.g. hook diathermy) and dissect to groin structures.
Identify testicular vessels and vas deferens.
Reduce sac intraperitoneally where possible (part reduce and excise apex where necessary).
Polypropylene mesh placed to cover from pubic tubercle to lateral to the deep ring; usually secured with laparoscopic tacking device.
Laparoscopic TEPS
Open cut down to pre-peritoneal space via umbilical port access; opening the peritoneum is avoided.
Open the pre-peritoneal space from umbilicus to groin (usually with assistance from a balloon dissecting device), then as for TAPS step 3.
Closure
Port sites 10mm and above require musculo-fascial closure.
Open, layers with absorbable sutures.
Post-operative care and instructions
Remove catheter (once fully mobile if open op with risk of ARU).
Complications (specific to the procedure)
Groin wound infection, <5%.
Recurrence, 3% lifetime.
Groin haematoma, 2%.
Painful scar/chronic groin pain, 1–2%.
Injury to testicular vessels (causing ischaemia), <1%.
Perforated peptic ulcer repair
Traditionally by an open approach, but now frequently done by laparoscopy since this offers complete abdominal assessment prior to proceeding and may allow a targeted long or lower midline laparotomy if other pathology is found.
Indications (typical)
Suspected perforated peptic ulcer from history ± CT imaging findings (see 
p. 284).
Pre-theatre preparation
Always GA, therefore NBM 2h and fluids only 4h preop.
Group and save required.
Ensure consent is obtained for proceeding to other procedures (e.g. bowel resection since other pathologies may be found).
Positioning and theatre set-up
Urethral catheterization. Fluid balance chart required post-operatively.
NGT. Not indicated.
Table positioning. Supine, but well secured to allow for head uptilt.
Monitor/stack position. Right cranial.
Steps of surgery
Open incision. Mini-vertical supra-umbilical laparotomy (may be extended).
Laparosopic. Establish laparoscopy (see p. 730).
Confirm diagnosis and identify site of perforation (duodenal, prepyloric or gastric).
Assess pathology. If suspicion of underlying malignancy in perforated gastric ulcer, consider if excision or partial gastrectomy may be required (senior help).
Repair is by patch closure of the ulcer wherever possible using omental tissue and not by sutured apposition closure of the defect (see Fig. 21.3).
Dissect a broad ‘tongue’ of omentum using diathermy (at least 5cm wide x 10cm long).
Three sutures placed through each edge of the ulcer, but not tied.
Omental strip laid under and secured in place by sutures (snug, but not tight).
Copious intra-abdominal lavage (all quadrants); drainage rarely required.
(a) Sutures placed in ulcer edges. (b) Omental patch in place.
Closure
Post-operative care and instructions
Antibiotics. Not required for simple peptic ulcer perforation.
Oral diet. Start liquid diet as soon as tolerated .
Complications (specific to the procedure)
Leakage at closure site, 5% (worst in immunosuppressed or advanced malignancy).
Haemorrhoid surgery
Surgical treatment is usually reserved for failed outpatient treatment (see p. 412) although the choice to go to surgery depends on symptoms, patient preference, and anatomy of the haemorrhoids.
Haemorrhoid de-arterialization procedures (blind or ultrasound-guided) are becoming more popular.
Indications (typical)
‘Conventional’ haemorrhoidectomy. Intero-external haemorrhoids (one or more).
‘Stapled haemorrhoidectomy’. Circumferential, prolapsing haemorrhoids, or extensive internal haemorrhoids resistant to outpatient treatment.
Pre-theatre preparation
May be GA or regional anaesthesia (e.g. low spinal or caudal).
Positioning and theatre set-up
Table positioning. Lithotomy.
Steps of surgery
Conventional haemorrhoidectomy.
(see Fig. 21.4)
Assess pedicle(s) to be excised and clarify which mucocutaneous bridges will be left at the end of the procedure.
Incise the external (skin) margin (caution to not over-excise; the skin defects enlarge easily!).
Develop subcutaneous/submucosal plane (superficial to internal sphincter); may be assisted with weak adrenaline solution injection.
‘Cone’ mucosal excision to apex of the pedicle.
Ligate or seal with energy source the pedicle origin and vascular supply.
(a) Extent of conventional haemorrhoidectomy. (b) Correct positioning of anorectal mucosal plication and stapling device.
Stapled haemorhhoidectomy
Determine anorectal mucosal ‘ring’ to be excised.
Anal dilatation with circular dilator and rotating ‘windowed’ retractor.
Circumferential running purse-string suture into mucosa and submucosa, avoiding circular smooth muscle (internal sphincter).
Placement of staple-gun anvil ‘head’ above the purse-string level and tightening-tying of purse-string.
Stapling device closed onto plicated mucosal ring, avoiding inclusion of anal canal lining by gentle eversion during closure.
Excision of anorectal mucosal plicated ring by stapling device and check of homeostasis.
Closure
No closure required.
Anal pack not usually required.
LA to conventional haemorrhoidectomy wounds.
Post-operative care and instructions
Laxatives. If prone to constipation.
Antibiotics. No proven benefit in reducing post-operative pain.
Complications (specific to the procedure)
Bleeding (requiring intervention), <5%.
Painful anal wound, 2%.
Anorectal leakage, 2–3%.
Anal stenosis, 1% (worse in conventional haemorrhoidectomy).
Pilonidal sinus excision (Bascom II)
Different options exist for excision and primary closure of a non-acutely infected pilonidal sinus (see p. 408)—Bascom I, Bascom II, Karayadakis, rhomboid flap, rotational flap. Principles of all primary closure procedures are:
Excision/extirpation of sinus disease.
Obliteration (elevation) of natal cleft.
Asymmetric closure of natal cleft (scar off the midline).
Indications (typical)
Symptomatic pilonidal sinus disease with unilateral or limited bilateral secondary cutaneous openings.
Pre-theatre preparation
Usually under GA, therefore NBM 2h and fluids only 4h preop.
Single dose antibiotics on induction.
Positioning and theatre set-up
Usually prone, sometimes with slight prone flexion at the hip. Buttocks may initially be taped laterally to aid retraction (should be released for final mobilization and closure).
May be performed in left or right lateral jackknife position, but symmetrical buttock position is hampered.
Steps of surgery (Bascom II)
(see Fig. 21.5)
Asymmetrical, semi-elliptical excision of sinus pit origins.
Choice of lateral extent usually determined by the site of any lateral tracks.
‘Rat's tail’ extension of cutaneous incision on the ‘short side’ to prevent final dig ear closure.
Excision of skin and pits only with preservation of subcutaneous fat.
Curettage, excision, and diathermy obliteration of all sinus tracks and lateral tracks.
Mobilization of cutaneous skin flap of ‘long side’ of the incision.
Mobilization of edge of skin flap of ‘short side’ of the incision.
Scrupulous haemostasis and wound wash-out.
Sutured closure apposition of natal cleft fat.
(a) Typical incision for midline pits (shown in dark grey) with extent of skin removal (shown in light grey). (b) Fat and flap closure to achieve natal cleft obliteration and para-midline scar.
Closure
Closure of skin flaps (interrupted mattress sutures—removable monofilament or dissolvable subcuticular suture).
Small calibre low pressure suction drain occasionally used for larger flaps.
Post-operative care and instructions
Remove catheter unless required for post-operative fluid balance observation.
Antibiotics. Only required for pathology found.
Oral diet. Normal as soon as tolerated unless indicated by further procedure performed.
Complications (specific to the procedure)
Wound infection, 5%.
‘Recurrent’ sinus formation (wound sinus formation or wound non-healing), 3–5%.
Painful scar, 2%.
Femoral embolectomy
Femoral embolectomy should only be undertaken where there are facilities for further vascular surgical exploration or procedures since underlying occlusive vascular disease and alternative diagnoses are common
Indications (typical)
Strongly suspected or proven acute embolic occlusion of the distal superficial femoral artery (SFA) or popliteal artery with acute critical limb ischaemia (see p. 642).
Pre-theatre preparation
May be GA or, more commonly, under LA.
Group and save and clotting required.
Ensure consent is obtained for proceeding to other procedures if they are anticipated.
Single dose antibiotics on induction.
Positioning and theatre set-up
Operating table should be X-ray compatible.
NGT. NOT required unless the patient is vomiting or gastric distension/surgery is likely.
Steps of surgery
(see Fig. 21.6)
Incision. Oblique groin over the common femoral artery.
Expose and control all inflow and outflow vessels (common femoral, superficial femoral, and profunda femoris).
3 or 4 FG Fogarty catheter is passed proximally and distally, and embolus retrieved.
If good inflow and good backflow achieved, then close with interrupted 6/0 prolene sutures and confirm return of distal pulses or reperfused limb.
Completion angiography may be undertaken on table (senior help).
On table, thrombolysis may be required if there is residual thrombus (senior help).
Surgical reconstruction or bypass may be necessary if there is in situ thrombosis on an underlying critical stenosis instead of simply embolism (senior help).
Consider fasciotomies (up to four compartments) if there is suspicion of a post-operative compartment syndrome (muscles are tense or tender or prolonged ischaemia >6h).
Vessel exposure and control. (A) Incisions for femoral and popliteal artery exposure. (B) Control of femoral artery and its branches. (C) Femoral embolectomy and closure without and with a vein prosthetic patch.
Closure
Subcuticular suture.
Post-operative care and instructions
Monitor pulse, BP, distal limb perfusion, pain, and pulses closely post-operatively.
IV heparin infusion—24 000IU over 24h by pump and check APTT at 4–6h and daily after. Also repeat APTT 4h after every change in dosage, keeping APTT at 2–2.5 times the normal range.
Start warfarinization at 48h.
Complications (specific to the procedure)
Haematoma formation, 5%.
False aneurysm formation, <1%.
Distal limb compartment syndrome.
Right hemicolectomy
Usually performed by laparoscopy although open access may be indicated for large or locally extensive tumours, previous abdominal surgery, inability to tolerate pneumoperitoneum. Laparoscopy may be multi- or single port.
Indications (typical)
Pre-theatre preparation
GA (NBM 2h and fluids only 4h preop).
Group and save required.
No bowel preparation usual for right hemicolectomy.
Single dose antibiotics on induction.
Positioning and theatre set-up
Urethral catheterization.
Table positioning. Supine, well secured to allow for head up/down tilt and lateral role.
Monitor/stack and ports positions. Right side (see Fig. 21.7).
Typical port sites and monitor position and extent of resection.
Steps of surgery (laparoscopic)
Dissection of right colon and ileum may be done from medial to lateral (starting at the ileocolic mesentry) or from lateral to medial (starting with the peritoneal attachments off the colon—one method is described below).
Establish pneumoperitoneum, assess access and peritoneal cavity.
(Head up and left down roll) Open and divide right gastrocolic omentum and divide peritoneum above the hepatic flexure.
Divide right paracolic peritoneum and reflect right colon medially.
(Head down and left down roll) Divide attachment of ileal and caecal mesentery to pelvic brim/iliac fossa peritoneum and reflect caecum superiorly.
Mobilize right colon mesentery from anterior pararenal fascia, anterolateral duodenum, and head of pancreas.
Isolate and divide ileocolic vessels and right colic vessels at mesenteric root.
Divide transverse colic and terminal ileal mesenteries.
Divide terminal ileum and proximal transverse colon (linear stapler).
Deliver specimen via (peri)umbilical incision and form ileocolic anastomosis (extracorporeal).
Closure
Post-operative care and instructions
Enhanced recovery programme usual. Oral fluids day 1, light diet day 2.
Complications (specific to the procedure)
Stoma formation
Indications (typical)
(see p. 84).
Pre-theatre preparation
GA if done as part of other procedures or if laparoscopically formed; may be LA/regional if isolated loop stoma formation.
Group and save required.
Ideal sites for proposed stomas should be marked by stoma specialist preoperatively unless emergency surgery.
Single dose antibiotics.
Positioning and theatre set-up
Table positioning. Supine unless required by related operation.
Steps of surgery
Ideally, any stoma should traverse the musculo-fascial layers of the abdominal wall (commonly the rectus abdominis); incisions in the fascia placed vertically with muscle fibres splayed apart (but not divided unless where necessary) to allow the stoma adequate space without ‘pinching’, but reduce the longer-term risk of herniation (a major problem especially in long-term stomas).
Loop ileostomy formation
Ensuring proximal and distal limbs are identified and orientated (if done as an isolated procedure via a trephine incision, this is difficult; the only reliable indicator is the antemesenteric fat ‘stripe’ leading onto the surface of the caecum; much more reliably done laparoscopically for direct visualization of each limb). Done before creating defect if laparoscopic procedure.
Opening of the antemesenteric wall of the loop (slightly oblique towards the distal limb).
Placement of sutures (untied) to ‘spout’ the proximal limb (see Fig. 21.8).
Placement and tying of sutures across the posterior wall of the loop and around the distal limb.
Tying the proximal limb sutures and spouting the proximal limb.
Suture placement for spouting of proximal limb of loop ileostomy.
A bridge is almost never necessary.
Closure
Port sites. As per laparoscopy.
Post-operative care and instructions
Oral diet. Normal as soon as tolerated unless indicated by further procedure performed.
Complications (specific to the stoma formation)
Stomal oedema, ∼30% (common and usually requires no treatment).
Stomal ischaemia, <5% (serious and requires prompt treatment).
Intestinal obstruction (due to tight musculo-fascial opening), 5%.
Stoma retraction (usually due to inadequate mobilization), <5%.
Stoma prolapse, <5%.
Stomal/parastomal hernias (rare acutely), up to 50% long term.
Wide local excision—breast
Indications (typical)
Carcinoma of the breast. Preferred to mastectomy for all, but large, tumours in small breasts, multifocal carcinomas, or those with multifocal DCIS and central tumours.
Pre-theatre preparation
Always GA, therefore NBM 2h and fluids only 4h preop.
Group and save required.
Consent may be required for additional procedures (such as axillary node surgery), especially if sentinel node detection is being used.
Positioning and theatre set-up
Radiography. Ensure mammograms or other radiographs are available.
Table positioning. Supine with arm extension to allow access to the axilla.
Steps of surgery
Skin incision according to breast folds and skin lines. Skin excision only required for superficial tumours with skin changes.
Dissection carried out in a column or wide sphere of normal breast tissue margin down to fascia of pectoralis major.
Haemostasis. Scrupulous care required.
Closure
Dissolvable sutures to fascia and skin.
Post-operative care and instructions
The specimen requires orientation with marking (by sutures or clips) to mark three out of the six ‘surfaces’: anterior, inferior, and medial surfaces—‘AIM’.
Drains not usually required but if so, remove once output.
Complications (specific to the procedure)
Breast haematoma, 5%.
Below knee amputation
Indications (typical)
Unreconstructible peripheral vascular disease of distal limb with critical ischaemia (involving vessels below the popliteal artery).
Acute unsalvageable distal limb ischaemia (involving vessels below the popliteal artery).
Unreconstructible trauma below the mid-tibia.
Tumours of the soft tissue or bone of the distal limb (some).
Unreconstructible congenital deformities of the foot with complications.
Pre-theatre preparation
May be GA; spinal or regional common in vascular disease.
Group and save required, may need cross-match for 2U.
Positioning and theatre set-up
Table positioning. Supine.
Ensure angiograms/limb CT scans available if appropriate.
Steps of surgery
(see Fig. 21.9)
Flaps used of below knee amputation. (a) Long posterior flap. (b) Skewed symmetrical flaps.
Two approaches are commonly used—‘long posterior flap’ and ‘skewed symmetrical flaps’. ‘Long posterior’ flap is more common, especially in ischaemia.
Long posterior flap
Mark flaps. Anterior flap slightly convex 10cm (in adults) below tibial tuberosity, just over hemicircumference of the calf skin. Posterior flap at least twice the length of the anterior flap. Opening of skin to fascia.
Opening and division of fascia, then muscles of anterior and lateral compartments with diathermy.
Identify anterior tibial neurovascular bundle; separate vessels and ligate; divide nerve under tension (promotes nerve retraction). Same for peroneal bundle.
Fibular, then tibial divisions (flexible, wire, or powered saw); division of fibula high; bevel front of tibia at 45°.
Striping of posterior compartment muscles off tibia and interosseous septum below level of the division to the extent of the posterior flap.
Identify posterior tibial neurovascular bundle; separate vessels and ligate; divide nerve under tension (promotes nerve retraction).
Trimming soleus and gastrocnemius to reduce bulk of posterior flap to allow comfortable coverage of bony stump.
Suturing of muscle/fascia to tibial peritosteum.
Closure
Skin and fascia. interruptible sutures.
Drain usually placed deep to myocutaneous flap.
Post-operative care and instructions
Early physiotherapy to knee joint to promote range of movements.
Complications (specific to the procedure)
Flap necrosis, <5%.
Haematoma.
