General Procedures

1. General Procedures • In this PowerPoint, you will find information on different types of “oscopies”, as well as Open procedures and their corresponding Laparoscopic procedures.

2. GI Endoscopic and Laparoscopic Procedures

3. Oscopies! • Sigmoidoscopy • Colonoscopy • ERCP • Choledochoscopy • Esophagoscopy • EGD

4. Oscopies! • Sigmoidoscopy • Flexible or rigid scopes are used. • Used to evaluate conditions of the rectum. • IV sedation is recommended.

5. Oscopies! • Colonoscopy • A procedure done to check for abnormalities in the colon. • Done under IV sedation • Biopsies, pictures, and brushings can be taken through endoscope.

6. Oscopies! • ERCP • (Endoscopic Retrograde Cholangiopancreatography) • Used in visualization of the soft tissues and sphincter fibers of the papilla and intraduodenal duct. • Can lead to ERS, Endoscopic Retrograde Sphincterotomy, which permit stones to move into the duodenum.

7. Oscopies! • Choledochoscopy • Visualization of the gallbladder, cystic duct and common bile duct using a scope.

8. Oscopies! • Esophagoscopy • Performed on the esophagus. • Used to evaluate pain or dysphagia (painful swallowing). • Can be used for foreign body removal, hemostasis, dilation, and biopsies. • Not to be confused with an EGD (Esophagogastroduoden-oscopy)

9. EGD • Esophagogastroduodenoscopy. • A diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum.

10. EGD Video • Old EGD Fast

11. GI Open ProceduresOperative Sequence Laparotomy

12. Laparotomy • Overall Purpose of Procedure: • An Exploratory Laparotomy is performed to examine he abdominal cavity when less invasive measures, such as x-rays and CT scans, fail to confirm a diagnosis. • Case length – 30 mins to many hours.

13. Laparotomy • Define the procedure: • Abdominal exploration may be used to help diagnose many diseases and health problems, including: • Inflammation of the appendix (acute appendicitis) • Inflammation of the pancreas (acute or chronic pancreatitis) • Pockets of infection (retroperitoneal abscess, abdominal abscess, pelvic abscess) • Endometriosis • Inflammation of the fallopian tubes (salpingitis) • Scar tissue in the abdomen (adhesions) • Cancer of the ovary, colon, pancreas, liver

14. Laparotomy • Inflammation of an intestinal pocket (diverticulitis) • Hole in the intestine (intestinal perforation) • Pregnancy outside of the uterus (ectopic pregnancy) • This surgery may also be used to determine the extent of certain cancers, such as Hodgkin's lymphoma (also known as Hodgkin's disease, a type of lymphoma characterized clinically by the orderly spread of disease from one lymph node group to another and by the development of systemic symptoms with advanced disease.) • Wound Classification: 1 (yet depends on what you do during the case)

15. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

16. Laparotomy • Instrumentation: Major/Minor Instrument Tray. • What basic instruments will you expect to see in this tray? • Positioning: The patient is in supine position, arms tucked at the side or on arm boards. Surgeon stands on the left side of the patient. • Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from midchest to groin area and far lateral on both sides. • Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.

17. LaparotomyBegin your Operative Sequence • Incision: 10 kb on #3 handle for incision. • A midline abdominal incision is made.

18. Laparotomycont. Operative Sequence • Hemostasis: Handheld Bovie, hemostats, free ties or clips are utilized.

19. Laparotomycont. Operative Sequence • Dissection and Exposure: • Army-Navys • Richardsons • Balfour • Bookwalter

20. Laparotomycont. Operative Sequence • Exploration and Isolation: • This entire step will depend on what procedure is needed! • Surgical Repair/Removal/Specimen Collection: • This entire step will depend on what procedure is needed!

21. Laparotomycont. Operative Sequence • Hemostasis and Irrigation: • All bleeding is controlled with cautery. • Use of warm Saline to irrigate.

22. Laparotomycont. Operative Sequence • Closure: • Will use strong suture for peritoneal layer such as 0 looped PDS. • Will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin. • Skin staples are always an option.

23. Laparotomy • Major Arteries: • Internal thoracic artery • The superior epigastric artery • Aorta • External iliac artery: the inferior epigastric and deep circumflex arteries • Inferior phrenic artery, branch of the abdominal aorta. • Lower posterior intercostal and subcostal arteries, branches of thoracic aorta. • Lumbar arteries, from abdominal aorta.

24. GI Laparoscopic ProceduresOperative Sequence Laparoscopic Appendectomy

25. Laparoscopic Appendectomy • Overall Purpose of Procedure: • Appendectomies are performed to treat appendicitis, an inflamed and/or infected appendix.An infected appendix can leak and infect the entire abdominal area, which can be deadly. • An irritated appendix can rapidly turn into an infected and ruptured appendix, sometimes within hours. A ruptured appendix can be life threatening. When the appendix ruptures, bacteria infect the organs inside the abdominal cavity, causing peritonitis. The bacterial infection can spread very quickly and be difficult to treat if diagnosis is delayed.

26. Laparoscopic Appendectomy • Define the procedure: Removal of the appendix with the aid of a laparoscope. • Wound Classification: 2 if not ruptured and no spillage of bowel contents during procedure. • Case length – 30 mins to 1hour.

27. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

28. Laparoscopic Appendectomy • Instrumentation: Laparoscopic Instrument Tray. • What other basic instruments will you expect to see in this tray? • Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient with the camera holder/assistant. Monitor should be placed near right hip facing towards surgeon.Trendelenburg? WHY? • Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from Chest to just above pubic hair and far lateral on both sides. Pre-prep hair trimming might be necessary. • Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.

30. Laparoscopic AppendectomyBegin your Operative Sequence • Incision: Two towel clips around umbilicus. • 15 kb on #3 handle for incision. • Veres Needle and CO-2 on high flow.

31. Laparoscopic Appendectomycont. Operative Sequence • Hemostasis: Can be from multiple means. The pressure of the trocars entering the pneumoperitineum will stop most bleeding. Bovie: either from the handheld pencil or L (or J) Hook is also available.

32. Laparoscopic Appendectomycont. Operative Sequence • Dissection and Exposure: • Total of 3 trocars should be used • Two 10mm (umbilical and left lower quadrant) and one 5 mm right upper quadrant trocar • The right upper quadrant trocar can be moved below the bikini line in females. • Camera/scope placed into pneumoperitineum. • In most cases, no other dissection or exposure is needed.

33. Laparoscopic Appendectomycont. Operative Sequence • Exploration and Isolation: • An atraumatic grasper [Endo Babcock, Maryland, Bowel Grasper, Dolphin Nose Grasper etc] is inserted via the right upper quadrant trocar. The cecum (from the Latin caecus meaning blind) is retracted upward toward the liver. In most cases, this will elevate the appendix in the optical field of the telescope. • The appendix is grasped at its tip with a 5 mm bowel grasper via the RUQ trocar. It is held in upward position

34. Laparoscopic Appendectomycont. Operative Sequence • Surgical Repair/Removal/Specimen Collection: • Left lower quadrant (LLQ) grasper is used to create a mesenteric window behind the base of the appendix. A grasper is used to create a mesenteric window under the base of the appendix. The window should be made as close as possible to the base of the appendix. • The base of the appendix is then separated from it’s cecal base with either an endo-loop suture and scissors or a stapling device. Visualization of the staple line is a must to insure no leakage of bowel content and no bleeding is present. • The mesoappendix (the portion of the mesentery connecting the ileum to the appendix) is divided and ligated, either with cautery or a stapling device. • Removal of the appendix with Endo-pouch • or Kellys/Peons

35. Laparoscopic Appendectomy

36. Laparoscopic Appendectomycont. Operative Sequence • Hemostasis and Irrigation: • The intra-abdominal cavity is irrigated thoroughly with normal saline. • All bleeding is controlled with a cautery-capable endo-instrument. • The abdomen should be examined for any possible bowel injury or hemorrhage. All the instruments and ports should be carefully and slowly removed while the CO-2 in the pneumoperitineum is released.

37. Laparoscopic Appendectomycont. Operative Sequence • Closure: • Closure will be surgeon specific. Some Surgeons today will not close any layer other than skin. • Other surgeons will use a 0-Vicryl to close the fascial/muscle layer and a 4-0 Monocryl for skin. • Skin staples are always an option.

38. Laparoscopic Appendectomy • Major Arteries: The appendix is supplied by the appendicular artery , branch of the ileocolic artery.

39. Laparoscopic Appendectomy • Major Veins: Theileocolic vein, a tributary of the superior mesenteric vein, drains the blood of the appendix. • Major Nerves: The nerves of the appendix are derived from the coeliac and superior mesenteric ganglia.

40. ReferencesSites of Interest • http://www.madsci.org/posts/archives/1998-02/887299251.An.r.html • http://www.laparoscopyhospital.com/Laparoscopic_Appendicectomy.doc • http://www.surgeryencyclopedia.com/A-Ce/Appendectomy.html • http://www.healthsystem.virginia.edu/UVAHealth/peds_digest/appendic.cfm • http://www.drugs.com/enc/appendectomy.html

41. Appy Video • Lap Appy per EES-Edu

42. Open Appendectomy • Overall Purpose of Procedure: • Appendectomies are performed to treat appendicitis, an inflamed and/or infected appendix.An infected appendix can leak and infect the entire abdominal area, which can be deadly. • An irritated appendix can rapidly turn into an infected and ruptured appendix, sometimes within hours. A ruptured appendix can be life threatening. When the appendix ruptures, bacteria infect the organs inside the abdominal cavity, causing peritonitis. The bacterial infection can spread very quickly and be difficult to treat if diagnosis is delayed.

43. Open Appendectomy • Define the procedure: Removal of the appendix via open approach. • Wound Classification: 2 if not ruptured and no spillage of bowel contents during procedure. • Case length – 30 mins to 1.5 hours.

44. Operative Sequence • 1- Incision • 2- Hemostasis • 3- Dissection • 4- Exposure • 5- Procedure (Specimen Collection possible) • 6- Hemostasis • 7- Irrigation • 8- Closure • 9- Dressing Application

45. Open Appendectomy • Instrumentation: Minor/Major Instrument Tray. • What basic instruments will you expect to see in this tray? • Positioning: The patient is in supine position, arms tucked at the side. Surgeon stands on the left side of the patient. Trendelenburg? WHY? • Prepping: Surgeon preference. Duraprep, Hibiclense or a Betadine Prep Kit. Prep from Chest to just above pubic hair and far lateral on both sides. Pre-prep hair trimming might be necessary. • Draping: Standard draping procedure. 4 towels and a lap drape. Ask about towel clips.

46. Open Appendectomy • Incision: McBurneys incision Which one is the McBurney?

47. Open Appendectomy • Hemostasis: Handheld Bovie, hemostats, free ties or clips are utilized.

48. Open Appendectomy • Dissection and Exposure: • Metz scissors and Debakey forceps. • Bovie for dissection and hemostasis • Army-Navy Ret, Small Rich or even Goulet for retraction and exposure of surgical site. • Possible need of Balfour Retractor in obese patients ONLY.

49. Open Appendectomy • Exploration and Isolation: • Bowel is mobilized with Babcock clamp. • Appendix is located and brought up through the incision site.

50. Open Appendectomy • Surgical Repair/Removal/Specimen Collection: • Moist towel is placed around the base of the appendix to keep incision site clean when “ectomy” is performed. • Using Metz scissors, the meso-appendix is isolated. • It is double clamped, cut and vasularity ligated with silk ties. • Why silk? • Uses 2-0 or 3-0 to tie. Have suture scissors ready.