SRINIVASAN MS

Dr. T,Senior Civil Surgjoon,

of Surgory
Sunior Asst. Profossor Hospital
CBE Modical Collugo
Coimbalora
Reg. No: 43248

TOTAL THYROIDECTOMY
INDICATIONS:
1. Carcinoma thyroid papillary, follicular & mcdullary
ANAESTHESIA:
General anesthesia

POSITION:
Supine with neck extended
INCISION:
Kocher's thyroid incision

OPERATIVE STEPS:
1. Under ETGA
patient in supine position, neck extended by placing a
Sand bag under the shoulder and table raised to 15 degree in thee
head end.
. Horizontal skin crease incision made 2
finger breadth above
sternal notch, extending from one sternocleidomastoid io the other
(Kocher's thyroid incision).
3. Platysma incised slightly at a higher level.
4.
T
Upper flap raised upto thyroid cartilage & lower ílap raised upto
sternoclavicular joint.
5.
Investing layer of deep cervical fascia opened vertically & strap
muscles are retracted. (In some cases if required they are
6. divided).
Pre-tracheal fascia opened & gland is reached.
7. Middle thyroid vein ligated in
8.
continuity & divided.
Superior pedicle ligated close to the gland (to avoid injury to the
external laryngeal nerve)
9. Inferior pedicle ligated away from the
gland (to
avoid injury to the
recurrent laryngeal nerve)
10. Similarly superior and inferior pedicles are
ligated on the opposite side.
11. The gland is dissected
by combined sharp & blunt dissection and
the whole gland is removed in toto with the
12. Hemostasis
capsule
obtained, drain placed & wound closed in layers.
HEMITHYROIDECTOMY
1. Indications: solitary nodular
goiter
2. Involved lobe along with isthmus removed.
is
SUBTOTAL THYROIDECTOMY:
1. Indications: Multinodular
goitre
2. About 8
gm/size of the pulp of little finger is left behind in the
tracheo-esophageal groove
 LICHTENSTEIN'S TENSION FREE HERNIOPLASTY

INDICATIONS:

1.Direct inguinal hernia

2.Indirect inguinal hernia
ANAESTHESIA:
1. Regional anesthesia

POSITION:
1. Flat supine position

OPERATIVE STEPS:
1. Area painted and draped.
2. Groin incision made % an inch above medial 2/3 rd of inguinal

ligament. of the
3. Superficial fatty layer and deep membranous layer that
vessels
superficial fascia opened along the incision.(small
Come across are cauterized)
4. External oblique is opened upto the superficial inguinal ring.
INDIRECT HERNIA:
the cordalong with sac and its contents are identified.
the cremastic fascia and intemal spermatic fascia are opened.
-cord is separated from the sac & cord lateralized.
-the sac is found lateral to the inferior epigastric artery.
-the sac is opened at the fundus & contents reduced.
-the sac is transfixed at the neck using chromic catgut and excess
sac excised.
DIRECT HERNIA:
-the cord is lateralized.
-the is medial to the iníerior epigastric artery.
-since the sac is a direct one sac is not opened and sometime it

may be sliding hernia.

-the defect in the posterior wal is closed with suturing fascia
transversalis using catgut.
5. A polypropylene mesh is placed.
6. It is fixed below taking first bite through periosteum of pubic
tubercle and along inguinal ligament.
7. The cord is medialised.
8. Above the mesh is fixed to conjoint tendon using prolene without
& any tension.
9. After perfect hemostasis wound closed in layers.
 PROCEDURE
WITH MULTIPLE
TRENDELENBURG

PERFORATORS LIGATION

INDICATIONS:
incompetence
with perforators
leg(Saphenofemoral
veins
1. Varicose
incompetence)

CONTRAINDICATIONS;

thrombosis
1. Deep vein
ANAESTHESIA: Regional anesthesia

POSITION: Supine

OPERATIVE STEPS:
is painted and draped.
1. The lower limb to be operated irom the site
made just below the groin starting
2. An oblique incision
to 5 cm medially.
of femoral artery pulsation GSV divided and
tissue dissected & 3 tributaries of
3. Subcutaneous
iliac
superficial circumflex
ligated.(superficial external pudendal
,

& superficial epigastric veins}

vein one close to the point
4. Clamps applied to great saphenous
and other distally.
whcre it cnters deep fascia
and disally and vessel cut
5. Double ligatures applied both proximally
that flush ligation of the SFJ is done
in between so
made over the site of incompetent
6. Small horizontal incision
perforators.
tissue GSV & perforators
7. After dissecting the subcutaneous
identified.
8. Perforator divided & ligated at the T'junction
are dealt with.
9. Similarly all the incompetent perforators
10. After perfect hemostasis skin sutured.
11. Elastocrepe bandage applied from toes to groin.
VENOUS STRIPPING:
vein is done till below knee joint and
1. Stripping of great saphenous
below knee perforators are ligated.
not done nowadays to avoid
2. Traditional stripping till ankle joint is
to the saphenous nerve.
injury
3. Here, after dividing and ligating GSV, a myer stripper is passed
through the GSV from groin & brought out through an incision
made just below the knee joint.
4. The knob is to the tip of the stripper & vein stripped from
applied
below upwards.
5. Elastocrepe bandage applied immediately to avoid hematoma

formation.
 INCISION AND DRAINAGE (HILTON'S METHOD
INDICATIONS:
1. Abscess

ANAESTHESIA:
1. General
2. Regional

POSITION: Supine
STEPS:
1. Broad spectrum antibiotics started.
Alter cleaning & draping, abscess is aspirated and
is confirmed. presence of pus
3. Skin is incised in the line parallel to neurovascular
bundle/langer's line in the most
dependant part
4.
prominent part or mOst
Abscess cavity is
opened using sinus forceps breaking
S.
possible septae. up all the
All loculi
6.
are broken up and is
Drain is pus drained.
.
kept.
Wound is not
closed and allowed
8.
culture sensitivity. to
granulate & pus is sent lor
Cleaning and dressing done.
 APPENDICECTOMY
INDICATIONS:
1. Acute appendicitis
2. Recurrent appendicitis

ANAESTHEIA:
General / regional anesthesia
POSITION OF THE PATIENT:
Flat supine position

INCISION:
1. Mc burney's
2. Lanz
3. Rutherford morrison's

OPERATIVE STEPS:
1. Area is
painted & suitably draped.
2 Mc Burney's incision is made over the Mc Burney's point and
subcutaneous fat divided.
3. External oblique aponeurosis is incised along the line of its
fibres
Internal oblique and transverses abdominis muscles are
identified and are split along the line of fibres.
5. Peritoneum picked up between two straight artery forceps &
opened along the line of incision.
6. Caecum delivered through the wound, tinea coli traced & base
of the appendix is identified.
Mesoappendix divided by clamping, dividing and ligating the
vessels.
8. Base of the
appendix crushed & ligature applied
9. Appendectomy done (stump 3 mm)
10. After perfect hemostasis, wound closed in layers, wound
dressing applied.
 INTERCOSTAL DRAINAGE

INDICATIONS:

Pleural collection
of pus/blood/air
1.

ANAESTHESIA:
Local anaesthesia

POSITION:
1. Sitting with pillow in the lap
2 Supine position

OPERATIVE STEPS:
The area (hemithorax ) painted & draped.
infiltrated with local
The skin of the 5th intercostal space is
anaesthetic agent down to the parietal pleura.
A stab wound is made in the 5th intercostal space mid axillary
3
line.
4 A trochar and cannula steadily pushed into the pleural cavity
along the upper border of lower rib.
5. Entry into the pleural space is identified by gush of pus/blood
air.
6. Trocar is removed & 1CD tube is quickly introduced.
7. Position of the tip of the tube is confirmed by thc drainage of
pus/air/blood through the ICD tube.
8. Tube is clamped temporarily.
9 The ICD tube is fixed to the chest wall using silk ligature &
adhesive tape
10. The tube is connected to water seal drain & the
Temoved
clamp is
11. Functioning of ICD is confirmed by the movement of water
column.
 VENOUS cUT DOwN
INDICATIONS:
When patient is in circulatory
2
collapse
Dehydrated state & all the
peripheral veins are in the
state collapsed
3 Extensive burns where other
peripheral veins are inaccessible
ANAESTHESIA: Local anaesthesia
POSITION: Supine

VEINS USED:
1. Great saphenous vein
2 Basilic vein

OPERATIVE STEPS
The leg painted & draped.
2 A 2 cm transverse incision is made 1 inch above & anterior to
medial maleolus.
3 Using artery forceps subcutaneous tissues are separated and
great saphenous vein is identified
Vein is stabilized by placing the stem of
5 The anterior wali of the vein is cut
arte y forceps under it.
transversely.
6. An intravenous catheter is introduced into the vein and fixed
using silk.
The lower end of the vein is ligated
8. After hemostasis wound closed in
layers, dressing applied.
9 Intravenous catheter connected to i.v set and fluid infused.
 CIRCUMCISSION

INDICATIONS:
1. Phimosis
2. Paraphimosis
3. Recurrent Balanoposthitis
4. Prepucial carcinoma
5. Religious
6. Genital Herpes

ANAESTHESIA:
1. General anaesthesia
2. Regional anaesthesia

POSISTION: Supine

OPERATIVE STEPS:
1. The external
2.
genitalia & perineum painted and draped.
The prepuce is
separated from any adhesion by introducing a
probe between the prepuce and the dorsal
as coronal sulcuas.
surface of glans as ior
3. Two fine artery
4. By a
forceps are placed on two sides of mid dorsal line.
scissor the mid dorsal line of
cm from the
the prepuce is divided to about 1
corona.
5. The
redundant parts of both
the line
6. All the
parallel to corona, halfprepucial layers are trimmed away in
cm distal to it.

7. Skin of
bleeding vessels are ligated.
the prepuce is
sutured to
interrupted catgut sutures taking the mucous membrane by fine
artery of the frenulum within one special precaution to secure the,
8. After of these
perfect hemostasis dressing ligatures.
applied.
 sUPRA PUBIC CYSTOTOMY

INDICATIONS:
1. Urethral stricture with retention of urine
2. Urethral injury with retention of urine

ANAESTHESIA:
1. General anaesthesia
2. Regional anaesthesia

POSITION
Flat supine position

REQUIREMENTS:
1. Fully distended bladder
OPERATIVE STEPS:
1. Lower abdomen
2. Vertical midline
painted
& draped.
suprapubic
3. Skin, subcutaneous tissue
incision is made.
& linea alba
4. Rectus and are divided
5. By means of
pyrimidalis
are retracted
laterally
gauze the peritoneum is stripped upwards and
anterior wall of bladder is
6. Two
exposed.
stay sutures are applied through relatively avascular part of
bladder wall.
7. The
stay lifted and a stab incision
sutures are
is made between 2
stay sutures on the bladder wall, evidenced by the gush of urine.
8. Wound is closed around the
catheter.
9. Abdominal wound is
closed with a drain in the retro
retzius & dressing applied. pubic of
space
10.Foley's catheter connected to Uro-bag.
 VASECTOMY

()
INDICATIONS: Done for the sterilization of males

ANAESTHESIA: Local anaesthesia

POSITION: Supine

OPERATIVE STEPS
Vas is identified at the neck
of the scrotum by palpating between 2
fingers.
2. It is fixed
by underpinning with a needle.
3. A small
incision is made in the scrotal skin
4. The
incision is right over the vas.
deepened through it's
pair of tissue forceps,vas iscoverings
. With a & vas is revealed
removed. picked up & the needie 1s
6. Two
artery forceps are applied on the
7. The vas 2 an inch
portion of vas between the apart.
8. Silk
ligatures are
forceps is excised.
applied to the cut ends of the vas
forceps are taken out.
9. Skin
and artery
incision is closed
10.Procedure repeated on with one suture.
the other side.
 MODIFIED RADICAL MASTECTOMY

INDICATIONS:
1. Early breast carcinoma stage lla, Ilb, Illa
2. Stage IIIb breast carcinoma after
downstaging the disease

ANAESTHESIA:
General anaesthesia

POSITION: Supine

INCISION:
1. Transverse Elliptical incision over the breast including nipple
areola complex.
2.
(Stewart Incision)
Oblique elliptical incision over the breast including nipple areola
complex.
OPERATIVE STEPS:
The area painted & draped.
Elliptical incision made over the breast including nipple areola
complex.
3. Incision deepened, upper flap raised
upto clavicle above, lower
flap raised upto 5th or 6th rib, medially upto lateral border of
sternum, laterally upto anterior border of Latissimus dorsi
muscle
Whole breast tissue with
nipple areola complex, skin over the
breast ,pectoral fascia are removed.
. After retracting the pectoralis
is excised along with
major muscle the pectoralis minor
b.
clavipectoral
The bleeders are cauterized
fascia.
Lateral pectoral nerve and branch of
thorocoacromial artery and
lateral thoracic artery should be
8 preserved.
Axillary clearance is performed upto level 3.
9. The clearance is continued until the
muscles of the
axillary wall are completely cleared off of all fatty and posterior
tissue glandular
10 Nerve to latissmus dorsi and nerve to serratus anterior are
preserved.
11. Thorough wash given.
12. After perfect hemostasis drain
a
placed and wound closed in
layers.
 EVERSION OF SAC
JABOULAY'S

INDICATiONS:
Hydrocele of scrotum

ANAESTHESIA:
Regional anaesthesia

POSITION:
Flat supine position

OPERATIVE STEPS
1. Area is
painted and draped
2.Vertical incision made over the involved scrotum at about 1cm from
the median raphe.
3. Incision deepened and tunica
4. The sac is
vaginalis reached.
.
separated from the surrounding layers and brought out.
The sac is héld in one hand
and with the other hand stab is made
Over the sac and
fhuid let out.
6. The sac is
everted and testis is brought out.
7. The sac is
sutured behind the cord.
F 8. The testis
is replaced into the
scrotum with sulcus
9. After
perfect hemostasis drain placed and wound facing laterally.
closed in
lajyers.

D
 TRUNCAL VAGOTOMY WITH POSTERIOR GASTRO
JEJEUNoSTOMY

INDICATIONS:
Gastric outlet obstruction due to cicatrized duodenal ulcer.
ANAESTHESIA:
General anesthesia

POSITION
Flat supine position

INCISION:
Upper midline incision
OPERATIVE STEPS:
1. Abdomen painted and
midline incision.
drapped.abdomen opened through upper
2. The left lobe of the liver is
mobilized by dividing the left triangular
ligament.
3. The
position of the oesophagus is guided by the nasogastric tube.
4. Peritoneum over the
abdominal part of esophagus is incised.
5. The phreno esophageal ligament is incised along the same
6. line
Finger is insuniated underneath to enter posterior mediastinum.
7. The stomach is pulled down and towards the
left.
8. The anterior trunk is found anterior
surface of esophagus and
posterior trunk lies some distance separate from the esophagu s.
9. About 5-7cm of both trunks are
excised and cut ends tied.
10.The deficiency in the hiatus is
closed with non absorbable
material
11.The greater
the laprotomy wound.
omentum, transverse colon are brought out through
12.The transverse mesocolon is
opened vertically in the avascular
plane to enter the lesser sac to the left of middle colic artery
13.A vertical fold of
posterior wall of stomach is höld with two
babcock's 3 inches apart.
14.The stomach opened inbetween the
clamps.
15.Now a loop of jejunum of about 10cm is
transverse mesocolon and two babcock's applied 3 inches
brought into the rent in
apart and the
jejenum opened inbetween the clamps.
is
16.A side to side anastomosis is done
between jejunum and
wall of stomach in 4 posterior
layers.
17.A posterior retrocolic isoperistaltic short loop no tension vertical
gastrojejenostomy is done
 aind wound closcld
placed
hemostasis Waslh given,drain
18.Atter pertect
i1n layerIS