CHAPTER 14

2. CHAPTER 14 General Surgery

3. Objectives • After studying this chapter, you will be able to: • Indicate the pathology and related terminology of each system or organ that prompts surgical intervention • Indicate special preoperative preparation procedures related to general surgery procedures

4. Objectives (cont’d.) • Recall the names and uses of general surgery instruments, supplies, and specialty equipment • Propose the intraoperative preparations of the patient specific to the illustrative procedures • Summarize the surgical steps of the illustrative general surgery procedures in this chapter

5. Objectives (cont’d.) • Identify the purpose and expected outcomes of the illustrative procedures • Determine the immediate postoperative care of the patient and possible complications of the illustrative procedures • Determine any specific variations related to the preoperative, intraoperative, and postoperative care of the general surgery patient

6. Part I: General Information • Introduction • General surgery involves many organ systems • Most commonly involves the abdominal cavity and organs contained within the cavity • General surgeon • Performs procedures on tissues and organs • Specific procedures • Refer to text

7. Instrumentation, Routine Equipment, and Supplies • Instrumentation • Many influential factors • Major set: refer to Figure 14-1 • Minor set: refer to Figure 14-2 • Biliary instruments: refer to Figure 14-3 • Intestinal instruments: refer to Figure 14-4 • Other general surgery instruments and sets: vary according to procedure • Routine equipment and supplies • Refer to text

8. Incisions • A variety of incisions are used to gain access to the abdominal contents • Refer to Table 14-3 • Incision type depends on: • Access desired • Procedure to be performed • Surgeon’s preference • Ability to lengthen the incision • Wound security and healing

9. Hernias • Protrusion of a viscus through an opening in the wall of the cavity in which it is contained • May be internal, interparietal, or external • May be congenital, acquired, or a combination • Types: refer to Table 14-4 • Hernia repair • Refer to Procedure 14-3

10. Surgery of the Alimentary Canal • Surgery on the digestive system • Constitutes the major portion of surgery performed by the general surgeon • Procedures • Many are variations on a common theme because of the tubular anatomical structure of the digestive tract

11. Esophageal Pathology • Pathological conditions of the esophagus fall into four major categories • Hiatal hernia and reflux esophagitis • Esophageal motility disorders • Neoplasms • Trauma

12. Laparoscopic Nissen Fundoplication • Surgical procedure performed to correct a hiatal hernia • Preferred operative procedure • Pathological conditions of the stomach • Refer to Table 14-6

13. Gastrostomy • Surgical creation of an opening from the gastric mucosa to the skin • Performed to provide nutrition “feeding” to the patient or to decompress and drain the stomach • May be performed in conjunction with a gastrectomy

14. Total Gastrectomy • Involves removal of the stomach and reconstitution of the alimentary tract • Subtotal gastrectomy types • Billroth I: removal of pylorus of the stomach and end-to-end anastomosis of remaining stomach and duodenum • Billroth II: cut ends of duodenum are closed and jejunum is anastomosed to the stomach

15. Bowel Pathology • Pathological conditions that affect the bowel • Refer to Table 14-8 • Principles of bowel resection and anastomosis • Numerous variations • Bowel anastomosis options • Refer to Table 14-9

16. Bowel Pathology (cont’d.) • Appendectomy • Performed for acute appendicitis or incidentally during other surgery as a prophylactic measure • Pathological conditions of the colon • Refer to Table 14-10

17. Stomas • Communication of a section of bowel with the outside of the abdominal cavity • Created to divert the fecal stream • Done temporarily to protect a recent intestinal anastomosis, to avoid potential abdominal spillage postoperatively, or an end result of bowel resection • Stoma types • Refer to Table 14-11

18. Anorectal Pathology • Pathological conditions of the anorectal area • Refer to Table 14-12 • Anorectal pathology presents with a variety of signs and symptoms • Refer to Table 14-13

19. Select Pathology of the Liver and Biliary Tract • Liver pathology and surgical conditions • Diagnosed via patient history, physical examination, changes in laboratory data, sonography, liver scan, CT scan, and biopsy • Biliary tract • Subject to the same diagnostic examinations • Select pathology and treatment of liver • Refer to Table 14-14

20. Liver Resection • Most commonly performed to excise hepatocellular tumor • Also performed as part of treatment for carcinoma of the gallbladder, to resolve uncontrollable bleeding or parenchymal maceration following abdominal trauma, or for transplant • Components of the liver • Refer to Figure 14-17

21. Liver Resection (cont’d.) • Surgical treatment of gallbladder disease • Sequence: conservative, noninvasive treatment; open cholecystectomy with cholangiogram; laparoscopic cholecystectomy • Conservative treatment for cholelithiasis • Includes medications or extracorporeal shock-wave lithotripsy

22. Cholecystectomy and Cholangiography • Cholecystectomy • Excision of the gallbladder • Primarily performed for acute cholecystitis • Performed through laparoscopic means in up to 90% of all cases, and this route is successful 95% of the time

23. Surgery of the Pancreas and Spleen • Spleen • Commonly traumatized and removed during emergency surgery • Cancer of the pancreas • Symptoms and diagnosis of pancreatic cancer: refer to Table 14-15

24. Pancreatectomy • Whipple procedure • Performed for managing tumors of the head of the pancreas • Requires both resection and reconstruction • Refer to Figure 14-21

25. Breast Surgery • Vast majority of breast cancer cases are female • Beast cancer is not limited to the female breast • Treatment of breast cancer • Multidisciplinary • Has received emphasis in finding a cure

26. Breast Surgery (cont’d.) • Breast and axilla: pathology and diagnosis • Breast cancer has been staged: refer to Table 14-16 • Tumor excision: refer to Figure 14-23 • Breast biopsy: accomplished with a needle or by surgical removal

27. Breast Surgery (cont’d.) • Modified radical mastectomy • Removal of the entire breast including axillary lymph nodes • Used in Stage I and II breast cancer or in conjunction with chemotherapy and radiation treatments for Stage III and IV breast cancer

28. Surgery of the Thyroid and Parathyroid • Thyroid gland • May fall within the realm of other specialties in some locales • General surgeon commonly operates on the thyroid and parathyroid glands • Pathological conditions affecting the thyroid and parathyroid • Refer to Tables 14-17 and 14-18

29. Surgery of the Thyroid and Parathyroid (cont’d.) • Thyroidectomy • Surgical removal of the thyroid gland • Parathyroid glands must be spared • A life-threatening condition associated with the parathyroid glands is tetany • If all four glands are removed, the patient will experience hypoparathyroidism, which causes hypocalcemia that leads to the neuromuscular symptoms of tetany

30. Summary • This chapter reviewed: • Preoperative preparation procedures related to general surgery procedures • General surgery instruments, supplies, and specialty equipment • Specific procedures performed • Immediate postoperative care of the patient and possible complications