Chapter 14 Flashcards

Question

What are some practical considerations for a laparotomy?

Answer 1

-Have Yankauer and Poole suction tips available. When using the Poole in the abd, surgeon may want to wrap a wet lap sponge around the tip to prevent tissue attaching -Surgeon may irrigate the abd cavity with an antibiotic solution mixed by CST at the back table in a graduated pitcher or bowl. -Variety of retractors will be needed

Answer 2

1. Midline skin incision is made and extended around the umbilicus. (Place lap sponges on each side of incision. Skin knife used. Have ESU and forceps ready) 2. Incision is deepened. (Deep knife used. As surgeon goes deeper, deeper retractors will be used. 3. Bleeding vessels are clamped ligated or cauterized. (Keep ESU cautery blade clean) 4. Using curved mayos, ESU, or scalpel, external oblique is opened the length of the skin incision-muscle splitting incision bc incision is in direction of fibers. (Keep clean laps on field) 5. Medium retractors are placed to retract the external obliques (Richardsons) 6. Internal obliques, transverse muscle, and transversalis fascia are split in the direction of muscle fibers up to the rectus sheath using scalpel or curved mayos, medium retractors are replaced with large Richardsons w longer blades to retract the internal oblique and transverse muscle. 7. Peritoneum is exposed. Small incision is made using smooth forceps to grasp/ elevate to prevent underlying bowel from being injured (Surgeon may prefer hemostat instead of forceps) 8. If abnormal fluid is encountered, sponges and suction are used as needed. Cultures will also be taken if necessary (Instruments/suction tips that come into contact w infectious fluid are contaminated and should not be used when closing) 9. Edges of peritoneum and transversalis fascia are grasped w Kocher on each lateral edge and slight traction is placed laterally. 10. Using metz, curved mayos, or scalpel, peritoneal incision is lengthened. The surgeon may insert the index and middle finger beneath the peritoneum to aid in elevating it and cut the tissue between the two fingers in the direction of the pelvis. 11. One or two vessels in fatty layer between fascia and peritoneum in the region of the umbilicus will need to be quickly clamped and ligated. 12. Richardsons are repositioned to allow surgeon to explore 13. Once affected, nonaffected, and anatomical landmarks are identified, Richardsons will be replaced with a large self-retaining retractor

Answer 3

1. Peritoneum is closed. (Counts should be completed before closure) If closed independently: edges of transversalis fascia is grasped w toothed forceps to expose peritoneum and edges of peritoneum are grasped with clamps. The clamps are crossed to bring edges together. Synthetic absorbable suture in continuous or interrupted fashion can be used. A medium ribbon retractor may be placed under peritoneal layer to keep the underlying organs pushed away from the suture line to avoid being sutured to the peritoneum. Internal oblique fascia is then closed with absorbable or nonabsorbable sutures in continuous/interrupted fashion. If closed in a single unit w fascia: heavy looped synthetic absorbable or nonabsorbable suture is used, #0 or #1 size; it is usually placed in continuous fashion. 2. Muscle may be sutured. 3. External oblique fascia and Scarpa’s fascia are separately closed w interrupted 3-0 absorbable sutures. (Smaller instruments are used as the wound becomes more superficial) 4. 3-0 or 4-0 absorbable, interrupted sutures in the subcuticular layer. 5. Skin could be closed by -edges being approximated by tooth forceps and sutured w 3-0, 4-0 silk or nylon on a cutting needle -Subq is closed w interrupted/continuous 3-0, 4-0, or 5-0 synthetic absorbable/nonabsorbable sutures. -Skin staples are often used to approximate the skin edges.

Answer 4

Accoding to procedure, pt is transported to PACU. Complications, wound healing/classification, and prognosis depends on pt condition, pathology that required surgery, and procedure performed.

Answer 5

1. hiatal hernia/reflux esophagitis 2. esophageal motility disorders 3. neoplasms 4. trauma

Answer 6

S&Sx: Acid reflux, mucosal erosion/ulceration/scarring, stricture, burning pain, pain is positional Dx: history, fluoroscopy while swallowing barium, endoscopy, and manometry Tx: medications that reduce acid production/reflux, diet/sleeping modifications, correction of anatomical defect, valve reconstruction in lower esophagus, and therapeutic endoscopy.

Answer 7

S&Sx: dysphagia, regurgitation of undigested food Dx: x-ray w contrast medium and cineradiography Tx: meds and endoscopic dilation

Answer 8

S&Sx: weight loss, pain, aspiration pneumonia Dx: Manometry Tx: therapeutic endoscopy and transection of muscle

Answer 9

S&Sx: regurgitation of recently swallowed material, choking, foul breath Dx: x-ray w contrast Tx: excision of diverticula and correction of cause

Answer 10

S&Sx: Dysphasia, weight loss, pain Dx: barium contrast study and CT scan Tx: radiotherapy, tracheostomy, extirpation of esophagus, and reconstruction

Answer 11

S&Sx: ingestion of caustic substance and perforation Dx: varies Tx: imediate intervention

Answer 12

surgical procedure that corrects a hiatal hernia

Answer 13

Abdominal esophagus extends from the esophageal hiatus to the opening of the cardia of the stomach. Abdominal esophagus lies in the esophageal groove on the posterior surface of the left lobe of the liver. At the point where it joins the stomach is a layer of circular muscle fibers called the lower esophageal sphincter (LES), which contracts to close the opening to the stomach and prevent food and gastric juices from reentering the esophagus. Hiatal hernia occurs when the esophageal hiatus is weak, which allows the abdominal esophagus and superior portion of the stomach to protrude into the thoracic cavity.

Answer 14

-Harmonic scalpel -Laparoscopic equipment -Insufflator -Laparoscopy instrumentation and laparoscopes -Liver retractor (fan retractor) -Coagulation hook -Grasping forceps -Laparoscopic ligating clip w clips -Trocars: 10 mm × 3; 5 mm × 2 -Minor instrument set -Laparotomy instrument set with additional long instrumentation (available for conversion from laparoscopic to open procedure)

Answer 15

-Maloney dilators -#11 and #15 knife blades -Laparoscopy supplies

Answer 16

-pt is positioned in supine w thighs slightly abducted and flexed or in 20 degrees Trendelenburg and in low stirrup -general anesthesia is used -skin is prepped from nipple line to mid-thighs and laterally as far as possible -Draping: Apply leggings if stirrups are used; square off with four towels–edge of upper towel placed mid-chest; lateral towels placed using anterior superior iliac spines as guide; edge of lower towel placed just above line of sympysis pubis; abdominal laparoscopic drape

Answer 17

-X-rays and barium studies in OR -Check all equipment -Surgeon usually stands between the patient’s legs, surgical assistant on the patient’s left, and the surgical technologist on patient’s right -Be prepared for conversion from laparoscopic to open procedure if complications arise

Answer 18

1. 5 Trocars are placed above the umbilicus, R and L subcostal, between the umbilicus and L subcostal, and under the xyphoid process. A 30 deg laparoscope is placed in the periumbilical port. (Order of trocars is 10 mm, 5 mm, 5 mm, 10 mm, 10 mm) 2. CST retracts L lobe of liver exposing esophageal hiatus 3. Lesser omentum is opened and R pillar of hiatus is identified. Extragastric vagal branches might be sacrificed. (Have laparoscopic scissors, coagulation hook, and ligating clips ready) 4. Incision is made in peritoneum and phrenoesophageal ligament is severed (Have grasper and dissector ready) 5. R pillar of the crus is dissected until lower L pillar is reached (prepare grasping forceps) 6. Grasping forceps are placed on stomach and retracted laterally and caudally. (Placed through uppermost trocar) 7. L pillar is localized and posterior vagus nerve is identified. Retroesophageal areas are dissected. (Have laparoscopic scissors, coagulation hook, ligating clips ready) 8. L pillar is dissected cephalad (Have 2-0 silk suture on needle holder, laparoscopic scissors, coagulation hook, ligating clips ready) 9. Grasping forceps are applied to the stomach and counter retraction is applied to expose gastrosplenic ligament. Vessels are isolated w coagulation hook and clipped. (make sure Maloney dilators are ready) 10. Fundus is grasped and passed behind the esophagus and regrasped on the other side. Maloney dilators are introduced to prevent torsion or stricture. 11. Interrupted 2-0 silk sutures are placed through stomach and anterior wall of esophagus to create gastric wrap (4-6). Mahoney dilator is removed and replaced w NG. 12. Hemostasis is achieved, instruments are removed, and incision is closed. (Have dressings ready)

Answer 19

-Pt is immediately transported to PACU -If no complications, pt returns to ADLs in 2-4 weeks -Complications include esophageal or gastric perforation; pleural perforation; conversion to laparotomy; dysphagia; necrosis of wrap or failure of the wrap; pulmonary infection; incisional hernia; SSI; hemorrhage; failure to gain relief from preoperative complaint.

Answer 20

Class I: Clean

Answer 21

S&Sx: Epigastric pain radiating to back, weight loss, pain from indigested food Dx: Bx, upper GI series, endoscopy Tx: Diet, meds, antacids, vagotomy, ulcer excision

Answer 22

S&Sx: NVD, bleeding, mucosal disruption, diffuse erythema Dx: Hx, upper GI series, endoscopy Tx: Withdrawal of noxious agents, stomach decompression, antacids, H2 blockers

Answer 23

S&Sx: asymptomatic Dx: endoscopy Tx: Bx, conservative tx

Answer 24

S&Sx: indigestion, pain Dx: Hx, endoscopy Tx: endoscopic/surgical removal

Answer 25

S&Sx: wt loss, epigastric pain, dysphagia, hematamesis, melena Dx: lab studies, upper GI, endoscopy, Bx Tx: Surgical resection

Answer 26

Surgical creation of a an opening (fistula tract) from gastric mucosa to skin in order to instill nutrition or drain gastric contents. May be lined w mucosa (long term) or serosa (temporary). May be performed in conjunction w a gastrectomy. Variety of ways tract can be created including Open- Placement of synthetic tubes (Stamm/Witzel) -Rolling gastric tissue into tubes (Spivak-Watsuji gastrostomy) Laparoscopic- Raising a flap of gastric tissue (Janeway gastrostomy) Percutaneous- Utilizing a transected portion of the jejunum

Answer 27

Cannot be inserted through the sterile field. Passed down the esophagus by anesthesia.

Answer 28

1. Skin site exit point is one-third of the way between the midclavicular line at the rib margin and the umbilicus 2. Placement site for incision is mid-stomach 3. Peds gastroscope is introduced and the stomach is insufflated 4. Finger is pressed on abd wall and indentation in stomach is observed through endoscope 5. Local anesthetic is injected at incision site and trocar needle is passed into stomach 6. Placement of needle is confirmed visually and trocar is removed 7. Wire/nylon loop is passed through the needle and snared by a loop in the gastroscope 8. Gastroscope is removed and snare is pulled PO where its attached to the gastrostomy tube 9. Procedure is reversed pulling the tube down the esophagus into the stomach w proximal end being drawn through the stab incision and secured

Answer 29

Tx for esophageal or stomach tumors or structures. The diseased portions of the esophagus and stomach are removed and the remaining sections are anastomosed.

Answer 30

1. Upper midline incision is made 2. Puncture wound is made on middle anterior wall of the stomach 3. A Foley/Malcot/Pezzer catheter is inserted and secured w two purse string sutures 4. The catheter exits the skin in the L hypochondriac region 5. The stomach is secured to anterior abdominal wall 6. The tube is secured to the skin 7. The abdominal wound is closed

Answer 31

In an antrectomy, the distal portion of the stomach and pylorus is removed. There are two types Billroth 1 and 2

Answer 32

Distal stomach is anastomosed to the duodenum

Answer 33

Distal stomach is anastomosed to the jejunum. This is preferred when the duodenum is scarred. The end of the duodenum is left closed.

Answer 34

Removal of the stomach used for cancer or when conservative treatment for ulcers fail. 1. Uses an upper midline, bilateral subcostal (chevron) or thoracoabdominal incision. (have self-retaining retractor ready) 2. The stomach is mobilized (have metz, hemoclip, and kellys ready) 3. Vessels of the stomach are ligated 4. A linear cutter is used to transect 1cm into the duodenum and across the distal esophagus freeing the stomach. (be ready for bowel technique) 5. Dissection is completed and esophagus is transected 6. Roux-en-Y esophagojejunostomy for reconstruction 7. Closure

Answer 35

18 inches of free jejunum is needed for tension-free loop and to precent reflex. There are two anastomoses: esophagojejunal and a jejunojejunal.

Answer 36

Remnant of structures within the fetal digestive tract that were not fully reabsorbed before birth. S&Sx: peptic ulceration, ileal mucosa inflammation, congenital fistula, anemia, malabsorption, anemia, hernia, hemmorrhange Dx: Hx, radionuclide scans, GI series, endoscopy Tx: Diverticulectomy and bowel resection

Answer 37

-Abdominal cavity nonreproductive organs -Abdominal wall hernias -Vein ligations -Muscle/nerve biopsies -Thyroid and parathyroid -Breast tissues -Lymphatic systems

Answer 38

To render the skin surgically clean to prevent SSI's. Should be applied in concentric, overlapping rings.

Answer 39

Allow for exposure of desired surgical access without exposing unnecessary anatomy.

Answer 40

Skin- Blade SubQ- Sponges/Bovie (for hemostasis) and retractors (for visulization) Linea Alba/Peritoneum- 2 kellys, deep blade, bovie, metz

Answer 41

-Minor set -Hemoclip applier/clips -Gastrostomy tube -Sterile catheter plug -Gastrostomy drainage bag

Answer 42

Position: Supine Anesthesia: General preferred; MAC or Local Skin prep: Mid-chest to mid-thighs and laterally as far as possible Draping: Square off; laparotomy drape

Answer 43

1. upper midline incision is made 2. stomach is identified and a site for tube placement on middle anterior wall is selected (have army navys or small richardsons) 3. site is elevated w a babcock and a puncture is made (have suction, babcock, and pursestring suture ready) 4. tube is inserted and secured w two pursestring sutures (instruments used to suture are dirty) 5. exit site in L hypochondriac region is identified and a stab wound is made and passed from opening to skin 6. stomach is secured to anterior abd wall 7. tube is secured to skin and incision is closed (place a sterile plug into a catheter)

Answer 44

S&Sx: Volvulus, obstruction, bleeding, pain Dx: GI series, endoscopy, CT Tx: resection for benign, wide resection for malignant.

Answer 45

S&Sx: fluid/electrolyte imbalance, sepsis, colic, distention, N&V, constipation Dx: Barium study, CT, GI studies Tx: Lysis of adhesions, resection Obstruction can include scar tissue, hernia, cancer, or swallowed items

Answer 46

A chronic inflammatory bowel disease that causes scarring and thickening of intestinal walls. Leads to obstructions, perforations, abscesses, and fistulas. May require resection

Answer 47

S&Sx: LLQ pain, palpable mass, fever, alteration of bowel habits Dx: Barium studies, H&P, endoscopy, x-ray Tx: Resection for ruptures or severe disease

Answer 48

S&Sx: elevated WBC, fever, rebound tenderness, RLQ pain Dx: physical, labs, CT/ultrasound Tx: Open/laparoscopic appendectomy

Answer 49

S&Sx: could be asymptomatic, change in bowel habits, blood in stool Dx: H&P, x-ray, CT, ultrasound, barium enema studies, colonoscopy Tx: Incision of polyp, hemicolectomy, colectomy

Answer 50

S&Sx: diarrhea, cramping, abd pain Dx: H&P, x-ray, barium studies, endoscopy Tx: continent ileostomy, colectomy w ileostomy

Answer 51

S&Sx: abd distention, cramping abd pain, N&V Dx: H&P, x-ray, barium studies, endoscopy Tx: Recection

Answer 52

Twisting of the intestine

Answer 53

1. Mobilize affected bowel 2. Pathological tissue is removed with healthy margins 3. Adequate blood supply to the remaining bowel must exist 4. Relatively equal diameter segments of bowel should be sewn back 5. Anastomosis should be tension-free and leak-proof 6. The mesenteric defect is closed 7. Function and anatomical continuity is continued

Answer 54

End to end: Attaching two ends of approximately the same size. End to side: Attaching the end of a segment of bowel to the side of one (T-like shape) Side to side: Creating parallel opening in two sections of bowel with anastomosis Roux-En-Y: used in partial or total gastrectomy, with pancreatic resection, and in surgery of the bile duct, and is an integral part of the Whipple pancreaticoduodenectomy

Answer 55

The confinement and containment of dirty instruments and supplies to prevent contamination of wound layers during closure. Includes anything used in anastomosis or rection of the alimentary tract.

Answer 56

-Clean and dirty areas should be separated (sterile basin to contain instruments/supplies and separate mayo) -sterile towels can be used to surround exposed bowel or cover drape near incision -ends after resection and anastomosis are checked for leaks -stoma creation is during the dirty part of the surgery. abd wound will be closed before stoma is matured and collection device is applied -nondisposable items in basin are handed off to circulator and disposables are put in biohazard bags -CST should change gown and gloves and help w regowning and gloving other members -new suction, bovie, and sponges should be put on field before closure

Answer 57

-Prophylactic antibiotics are routine bc colon has the largest population of flora. Bowel prep is done to cleanse preop -Extensive prep-site (nipple to mid-thigh and bilateral as possible. if there is stoma creation, location will be marked preop) -Principles of anastomosis are applied -Ligament and large vessel excisions -Hemicolectomy is usually for cancer where 5 cm distally and proximally are taken depending on blood supply

Answer 58

1. midline incision is made/lapartomy is performed. the surgeon runs to colon to inspect and determines what needs to be removed 2. section of colon to be removed is mobilized 3. surgeon may cover the wound w towels or sponges to protect the peritoneal cavity and isolate the section 4. four intestinal clamps are placed (2 at each end). colon is divided and placed into a basin which is passed off. remember in count bc clamps may still be attached 5. Anastomosis is performed. Since intestine may be at an unequal diameter, smaller colon might be cut at a slant or side to side anastomosis might be used. Colostomy might also be done instead. 6. second layer of suture is done (absorbable) 7. third layer of suture is done (interrupted silk or vicryl) 8. bowel technique ends 9. laparotomy closure 10. if colostomy was created, it will be matured after closure of abd wound.

Answer 59

-major set w extra kellys and peans -long and deep set -GI set w bowel clamps -large self retaining retractor -extra needle holders, scissors, and thumb forceps -large diameter ties -foley -drain -extra laps and towels

Answer 60

Communication of a section of bowel with the outside of the abdominal cavity that is created to divert the fecal mater

Answer 61

Temporary: Used as diversion to protect recent bowel anastomosis or to avoid abdominal spillage postop Permanent: A result of bowel resection

Answer 62

From an end section or a loop of the colon of ileum

Answer 63

Single: End stoma that is usually permanent Two: One functioning and one not functioning. Usually temporary

Answer 64

-Contact dermatitis -Stomal prolapse -Stenosis -Stomal retraction -Parastomal hernia -Fistula formation -Bleeding varices -Appliance leakage -Ischemia -Offensive odors -Laceration -Urinary tract calculi -Gallstones -Infection -Hyperplasia -Bowel obstructions

Answer 65

Ideal: Below the costal margin, above the belt line, and lateral of the rectus abdominus -Chosen and marked prior to sx (reviewed in sitting and standing positions) -Some cases may be a result of intraop of decision making

Answer 66

End ileostomy: from a terminal portion of ileum and can be temporary and permanent Loop ileostomy: A temporary stoma for fecal diversion End-loop ileostomy: modification of the loop method where the loop is divided w a GIA and both ends are brought out through the incision End colostomy: created from descending and sigmoid colon Loop colostomy: Utilizes the transverse colon. Not generally permanent since discharges a semiliquid stool. The most frequent for fecal diversion End-Loop Colostomy: The loop is divided with a linear cutter and both ends are brought out through the skin incision

Chapter 14 Flashcards

General Surgery