OPERATIVE PROCEDURES

 Venous cut down(For cannulization)

 Drainage of breast abscess

 Thyroidectomy

 Colostomy

 Appendicectomy

 Cholecystectomy

 Inguinal hernia surgery

 Supra-pubic cystostomy

 Vasectomy

 Orchiectomy

 Hydrocele surgery

 Circumcision

 Intercostal tube drainage

 Venous cut down (For cannulization)
Anaesthesia- Local.

Indications - Thrombosis of superficial vein.

-Collapse of due to dehydration.
-Larger cannula insertion for rapid infusion of fluids in shock.

Procedure-The median cubital vein in elbow or great saphenous vein in lower limb is chosen. 2
ml of local anaesthetic drug is infiltrated intra-dermally in a line transversely across the vein,
and a small incision made. The superficial fascia is cleared by insertion of sharp scissors. When
the vein has been isolated, two ligatures are passed around it; the distal one is tied and held in
forceps, the proximal one is half tied in readiness to receive cannula and ends are left loose.
With sharp pointed scissors a nick is made in the vein between the ligatures, the distal one
being used as a retractor. The cannula which should have been filled with infusion solution to
exclude air bubbles is quickly inserted and proximal ligature is tied to enclose it. The skin wound
is closed with two mattress sutures.

Drainage of breast abscess

Anaesthesia – G.A.

Indications& procedure- Unless the inflammation settles quickly by antibiotic therapy for 2-3
days, drainage of pus should be considered. The incision should lie radially or peri-areolar over
the area of maximum tenderness. When the pus comes out, a gloved finger should be
introduced and all the loculi (fibrous septa) are broken. If the abscess cavity extends deeply, a
dependent drain (corrugated plastic) is put. Pus is sent for culture and suitable antibiotic
continued. Retro-mammary abscess may be tubercular, in which the skin incision is closed and
anti T.B. drugs started.

Thyroidectomy
Indications- simple diffuse goiter for cosmetic reasons or to relieve pressure symptoms on
adjacent structures, simple nodular goiter, toxic diffuse goiter, toxic nodular goiter, carcinoma
thyroid.

Pre-operative preparation- Routine laryngoscopy is done to assess vocal cord function.

Medical treatment before surgery with iodine (Lugol’s solution), Propranolol; in severe
thyrotoxicosis anti-thyroid drugs given.

Anaesthesia- G.A.
Types- Subtotal, hemi-thyroidectomy, near-total, total and radical thyroidectomy.

Technique of subtotal thyroidectomy(4gm on each side kept)-A pillow is placed between

shoulders so that neck is extended. A transverse incision is made 2-3cm above sternum parallel
to Langer’s line extending to the lateral borders of sternomastoid muscle. Flaps of skin,
superficial fascia and platysma are divided and reflected upwards to the level of thyroid
cartilage and downwards to the sternum. The investing layer of deep fascia is incised vertically
in midline. Interval between infra-hyoid muscles is opened to expose pre-tracheal fascia
(sheath) covering the gland. The sheath is now incised; larger lobe dealt first. A finger is used to
clear the lateral surface of lobe. The middle thyroid vein is ligated and divided. Muscles are
retracted upwards and laterally to deliver the upper pole of gland. The superior thyroid vessels
(vascular pedicle) are ligated and divided. The inferior thyroid vessels are ligated as far possible
to avoid injury to recurrent laryngeal nerve. With a dissector the gland is separated from
trachea. The gland is sectioned with a knife keeping the required amount of thyroid tissue. The
opposite side of gland is treated in similar manner. The wound is closed, drainage is provided by
suction drain.

Hemi-thyroidectomy (lobectomy)- The entire one thyroid lobe with the isthmus is removed
preserving the parathyroids.

Near total thyroidectomy- 1-2 gm. on unaffected side is preserved and rest gland removed.

Total thyroidectomy- This technique is bilateral version of hemi-thyroidectomy. If parathyroid

cannot be preserved, then they are re-implanted into sternomastoid muscle.

Radical thyroidectomy- total thyroidectomy with removal all nodes.

Complications of thyroid surgery

 Haemorrhage- Cause dyspnea on pressure over trachea. Treated by evacuation of clot
and securing bleeding point.
 Respiratory obstruction- Due to laryngeal oedema and vocal cord palsy.
 Recurrent laryngeal nerve palsy- Usually results from pressure from blood clot and
tissue oedema; recovery is expected in few days. If nerve is cut, recovery is poor.
 Thyroid crisis- Occurs in hyperthyroid state due to inadequate preoperative treatment.
 Hypothyroidism –Rarely occurs after hemi-thyroidectomy; treated by L-thyroxine.
 Hypoparathyroidism- Tetany may be transient; treated by calcium gluconate and
vitamin D.
 Wound infection.
 Granuloma or keloid.
 Colostomy
Colostomy is an artificial opening made in the large bowel to divert faeces and flatus to the
exterior, where it can be collected in an external appliance. It may be temporary or permanent.

Indications- colon or rectum cancer, intractactable high fistula-in-ano, Hirschprung’s disease,

resection in volvulus of pelvic colon.

Sites of colostomy-Transverse colon, pelvic (sigmoid) colon.

Defunctioning colostomy- Any colostomy is regarded as ‘defunctioning’ if it is so constructed

that faeces are prevented from entering the bowel distal to it.

Temporary colostomy- Most commonly done to defunction an anastomosis after an anterior

resection to prevent leakage and peritonitis. A loop of colon is brought to surface where it is
held in place by a plastic bridge passed through mesentery. Once abdomen is closed the
colostomy is opened and edges of colonic incision are sutured to the adjacent skin margin. The
bridge can be removed after 7 days, when firm adhesion of the colostomy to the abdominal
wall has taken place. Most loop colostomies are made in the transverse colon, but the sigmoid
colon can also be suitable following healing of the distal lesion for which the temporary stoma
was constructed, the colostomy can be closed. Closure is done after stoma is mature, i.e. after 2
months.

Permanent colostomy- This is usually performed after excision of rectum for carcinoma by
abdomino-perineal technique. It is formed by bringing the distal end (end colostomy) of the
divided colon to the surface in the left iliac fossa, where it is sutured in place joining the colonic
margin to the surrounding skin. The best site is through the lateral edge of rectus sheath, 6cm
above and medial to the bony prominence for better fitting of colostomy bag.

Colostomy complications- Prolapse, retraction, necrosis of distal end, stenosis of orifice,

colostomy hernia, colostomy diarrhoea.
Appendicectomy
Anaesthesia– G.A./ spinal

Indications- acute appendicitis

- recurrent appendicitis
-carcinoid tumour of appendix.

Incision- A right gridiron/Lanz incision/Rutherford-Morrison incision(Muscle-cutting).

Gridiron incision is muscle splitting over the Mc-Burny’s point perpendicular to the line joining
right ant.sup. iliac spine and umbilicus. Lanz incision is transverse in right iliac fossa.
Procedure-The caecum is identified by presence of taenia coli. It is grasped by left hand and
pulled towards lower end of wound, then appendix should follow into the wound. If not, it is
located by a finger passed along the anterior taenia coli where all all taenia meet at the base of
appendix. Then appendix is delivered by finger and held by Babcock’s forceps. The
mesoappendix is clamped and divided. A forceps is applied to the base of appendix and a
ligature is tied over the crushed area. A purse-string suture is inserted in caecal wall around
base; then appendix divided and appendix stump is buried by tightening the purse-string
suture. The operation is completed by suturing of the wound in layers.

Postoperative complications- Pelvic abscess, sub-phrenic abscess, fistula formation.

Open cholecystectomy
Indications- Gall stone, cholecystitis, gall bladder carcinoma. It is also done if laparoscopic
cholecystectomy fails.

Preparation for operation- Liver function tests done. High carbohydrate diet is given to ensure
glycogen stores in liver, adequate hydration and vitamin K supplement in jaundiced patient.

Incisions- Right para-median (for narrow costal angle), Kocher’s subcostal (for wide costal
angle), right upper quadrant transverse (good cosmetic).

Technique- Three packs are given; the first on duodenum, the second over stomach and the
third over right kidney. Retractors are placed and held by assistant for better exposure.
Two methods –1) The retrograde method. This is commonly advocated to reduce injury
to CBD and right hepatic artery. The cystic duct and cystic artery are ligated first and gall
bladder is stripped off towards the fundus. A sponge holding forceps is applied at infundibulum
to draw gall bladder. Then junction of cystic duct and common hepatic duct is displayed. An
absorbable suture is placed loosely around cystic duct. Any stones in cystic duct are milked
towards gall-bladder and cystic duct is now divided between two ligatures. The cystic artery is
searched crossing triangle of Calot and ligated and divided with silk. The gall bladder is only
attached by peritoneal sheath to lower border of liver. By finger dissection it is separated from
liver bed and peritoneal reflections cut with scissors. Gall bladder is removed. Minute bleeding
from liver bed is arrested by pressure.
Suction drainage is provided to drain any leakage of bile or to drain any oozing of blood.
Wound is closed in layers. Drain is removed after 48hrs if no leakage occurs.
2) ‘Fundus first’ method- This method is advised when difficulties
(previous inflammation) prevent ducts to be displayed. Separation of gall bladder is
commenced at fundus. The peritoneal reflection from liver is divided with scissors. The cystic
duct and artery are defined and divided.

Risks of operation- Injury to main bile ducts or right hepatic artery, haemorrhage from cystic
artery due to slippage of ligature, external biliary fistula due to leakage of bile.
 Inguinal hernia surgery
Indications-All inguinal hernia should be treated by surgery. A truss should be prescribed only
when patient refuses surgery.

Anaesthesia- General/spinal/local; any can be tried.

Herniotomy for infant or child- A preformed sac is present, so removal sac alone is sufficient.
The sac is opened, contents reduced and neck is transfixed and sac excised.

Herniorrhaphy over the age of 16yrs- This consists of-1) herniotomy 2) repair of defect in
posterior wall.
Technique- Herniotomy-An incision is made 2.5cm above and parallel to the medial three-fifths
of the inguinal ligament. The incision is deepened until the aponeurosis of external oblique and
superficial ring are exposed. Cord is identified. The aponeurosis is divided; upper edge of
aponeurosis is retracted to expose the conjoint tendon; lower edge retracted to expose inguinal
ligament. The ilio-inguinal and ilio-hypogastric nerves are identified and safeguarded. The cord
ifs lifted up and spread out on finger. Sac (pearly white) of hernia is identified and dissected. Sac
is opened at fundus and contents reduced by finger. Neck is transfixed and excised.
Repair- In Bassini’s method, conjoint tendon is stitched to inguinal ligament behind cord
by non-absorbable sutures. In Shouldice operation, double breasting of fascia transversalis and
conjoint tendon is stitched to inguinal ligament. Implantation of foreign material
(Proline/nylon/marlex/Dacron mesh) is done in posterior wall where the defect is large as in
recurrent hernia- hernioplasty called Liechenstein’s repair.

Suprapubic cystostomy
A tube is placed in the bladder for drainage.

Indications- Retention of urine when urethral catheter cannot be passed, as part of operation
on the bladder, prostate, or urethra.

Anaesthesia- local.

Procedure- Two types;1) by open method,2) percutaneous method.

Open method- This allows exploration of bladder and placement of tube at a higher level on the
abdominal wall than percutaneous method. By either vertical midline/horizontal incision,
bladder is exposed and a small incision is made into it as high as possible between stay sutures.
The bladder is emptied by suction and interior is explored with a finger to exclude calculi,
tumour and diverticula. A self-retaining catheter(Foley or Malecot type) is introduced and
bladder wall is sutured around it with one or two catgut stitched. The catheter is brought out
through a stab wound in the abdominal skin flap.
Percutaneous method- can only be done safely if bladder is distended. A 2cm incision is made
5cm above pubis through skin and linea alba. Suprapubic cannula and trocar are introduced
into bladder. The trocar is withdrawn and cannula is closed with a finger. A well lubricated Foley
or Malecot catheter is introduced with the introducer. The cannula and introducer are
removed.

N.B.-Urinary bladder is identified by its fasciculated appearance and thin walled veins on its
surface.

Vasectomy (Division of vas deferens)

Indication- to effect male sterilization.

Anaesthesia- local

Procedure- The vas is identified, then grasped and steadied under skin with the thumb and
index finger of left hand. A small volume of local anaesthetic injected. A 1cm transverse incision
is made over the cord and cord picked up with Allis forceps. The proximal end is ligated and
divided by 2-0 absorbable material. The distal end is ligated 1.5 cm away and intervening
segment excised. It is important to separate the cut and ligated ends of vas by a gap, because
regeneration can occur. The skin then sutured.
The operation can be done through lateral incisions one for each vas.

Orchiectomy
Indications – malignant tumour of testis, undescended testis if discovered after puberty,
gangrene of testis in torsion, repair of recurrent indirect inguinal hernia in elderly, carcinoma of
prostate, granulomatous diseases of testis.
Anaesthesia- Local

Procedure- two types; 1) inguinal approach, 2) scrotal approach.

Inguinal approach- done for malignant disease of testis and hernia repair. Through an incision
above inguinal ligament, the inguinal ligament is opened. The spermatic cord is mobilized to the
deep inguinal ring where it is divided between ligatures. The cord and testis are mobilized and
removed.

Scrotal approach- Done through a scrotal incision. The spermatic cord is ligated at the
superficial ring. Skin is closed with a dependent corrugated drain.
 Hydrocele surgery
Anaesthesia- General/spinal/Local anaesthesia.

Lord’s method- The hydrocele is grasped with left hand and anterior scrotal skin stretched.
Incision is made through the skin and dartos muscle. Vessels are ligated. Tunica vaginalis is
opened by same length incisionand hydrocele fluid evacuated. The testis is now lifted out
through the incision. If the hydrocele is large, sac may be excised. Five or six ‘gathering ‘stiches’
are now inserted with absorbable suture into the evaginated tunica, radiating outwards from
attachment of testis. When sutures are tied, the tunica is plicated. Finally testis is returned to
the scrotum. Skin and dartos muscle are stitched in one layer.

Jaboulay’s method- Done if the hydrocele is small. The incision is same. It consists of simply
turning the sac inside out(eversion)so that it lies entirely behind testis, then a few sutures are
inserted to retain its position.
Complications of hydrocele operation-Haematoma.

Circumcision
Indication- Phimosis, paraphimosis, and recurrent balanitis, assessment in carcinoma penis or
religious purpose.

Anaesthesia- G.A.in children and local in adults.

Procedure in children – The tip of the prepuce is grasped by two forceps and pulled forward
with light traction. A narrow clamp (Hollister Plastibel) is placed obliquely across prepuce distal
to glans parallel to corona and prepuce is then divided immediately distal to the clamp. As the
clamp is released, the outer layer will retract and inner layer is trimmed to leave 0.3cm cuff
around corona glandis. Haemostasis is maintained; no monopolar cautery is used as it may
coagulate the major blood vessel of penis. Finally the inner and outer layers of prepuce are
closed with fine interrupted absorbable sutures.

Circumcision in adult- The clamp method is unsuitable as prepuce is seldom long in adult. Three
small artery forceps are applied to the edge of prepuce, one in midline ventrally, two (side by
side) in the midline dorsally. The prepuce in mid-dorsal line is slit between two dorsally placed
forceps as far as corona. The inner layer of prepuce is trimmed in the same way leaving about
0.5cm longer than skin. The cut edge of skin is sutured to the cut edge of inner layer of prepuce
with 4-0 absorbable suture.
 Intercostal tube drainage
Anaesthesia - Local with 1% Lignocaine( about 10 ml).

Indications – Collapse of the underlying lung secondary to pleural collection of air or fluid like
blood/pus.

It is a life-saving maneuver. While small pneumothorax can be managed conservatively;

tension pneumothorax requires immediate drainage. A wide-bore needle is inserted into the
second intercostal space 5cm from midline is sufficient until formal drainage can be performed.

Procedure – Prior to insertion of drain, X-rays (AP/Lateral) are carefully examined. The drain is
inserted into the fourth intercostal space in triangle of safety (bounded by upper border of fifth
rib and pectoralis major muscle anteriorly and latissimus dorsi muscle posteriorly).

The drain is angled up for pneumothorax and down for fluid.

The patient sits upright on bed leaning forward with the arm held across the opposite
shoulder. Anaesthetic drug is infiltrated to skin, subcutaneous tissues, muscles and pleura. An
incision 1cm oblique on upper border of 5th rib is continued through the subcutaneous tissue.
The intercostal muscles are separated with blunt scissors until pleura is breached. The drain
mounted on a trocar, is inserted. The drain is anchored with securing stich is connected to an
underwater seal bottle. Air will be seen to bubble out or fluid will drain. Under water seal
system allows one-way escape of air/fluid from pleural cavity.

A chest X-ray confirms satisfactory placement of tube. The drainage system is kept at
floor level and water changed daily. Daily X-rays taken to confirm successful removal of
air/fluid. Presence of bubbling in the underwater seal when patient coughs suggests a
continuing air leak even if lung appears expanded on X-ray.

Complications- 1. Failure to drain because of wrong site placement or small caliber tube.

2. Injury to liver or spleen.

3. Excessive blood loss due to injury to underlying lung/intercostal vessel.

4. Infection may occur if tube is placed more than 7 days.