ABDOMINAL SURGERY

LAPAROTOMY - surgically opening the abdominal wall and entering and entering the peritoneal cavity.

FASCIA – covers the muscles anteriorly and posteriorly. PERITONEUM – the thin-serous membrane that lines the interior of the abdominal

cavity (parietal peritoneum).

TERMS ASSOCIATED WITH LINES OF DIRECTION FOR SURGICAL INCISIONS (USING THE UMBILICUS AS REFERENCE POINT)*Midline / Longitudinal – centered above or below the umbilicus.Paramedian – right or left of the umbilicus, above or below umbilicus.Subcostal / Oblique (Kocher) - above umbilicusTransverse – above or below the umbilicusMc Burney – right sideInguinal – right or left sideHorizontal flank – right or left sideUmbilical (supraumbilical or infraumbilical) – above or below umbilicusPfannenstiel – langer line just above the pubisChevron – multiangle oblique subcostalPuncture/stab – can become round or obliqueFemoral – right or left side

- Various types of incisions are used in laparotomy, but each follows essentially the same technique.

- Before procedure begins, the surgeon chooses the most suitable incision for the procedure being performed.

CHARACTERISTICS:

Ease and speed of entry into the abdominal cavityMaximum exposureMinimum traumaLeast postoperative discomfortMaximum postoperative wound strength

TYPES OF ABDOMINAL INCISIONS:

-DIRECTION AND LOCATION are the two main factors governing the type of the abdominal incision.

-incisions may be vertical, horizontal or oblique and may occur in various areas of the torso.

-Laparoscopy is performed through multiple (usually 2 to 5) incisions that are smaller (usually 5 to 10 mm), separate and distinct.

1. PARAMEDIAN INCISION – is vertical incision made approximately 4 cm (2 inches) lateral to the midline on either side in the upper and lower abdomen.

-this incision allows quickly entry into and excellent exposure of the abdominal cavity.

-it limits trauma, avoids nerve injury, is easily extended, and gives a firm closure.

2. LONGITUDINAL MIDLINE INCISION – can be upper abdominal, lower abdominal, or a combination of both going around the umbilicus.

-upper midline incision offers excellent exposure of and rapid entry into the upper abdominal contents.

3. SUBCOSTAL UPPER QUADRANT OBLIQUE INCISION – begins in the epigastrium and extends laterally and obliquely just below the lower costal margin.

-this type of incision affords limited time of exposure except for upper abdominal viscera.

-it provides good cosmetic results because it follows skin lines and produces limited nerve damage.

-use include biliary procedures and splenectomy.

-BILATERAL SUBCOSTAL INCISIONS that join in the midline may be preferred for procedures that involve the stomach and/or pancreas.

-BILATERAL MODIFIED SUBCOSTAL INCISION (CHEVRON INCISION) is made for increased visibility during the liver transplantation or resection.

4. MC BURNEY INCISION – located at the right lower quadrant, just below the umbilicus and 4 cm medial from the anterior superior iliac spine.

-it involves a muscle- splitting incision that extends through the fibers of the wound.

-examples of use include choledochojejunostomy and transverse colostomy.

5. PFANNENSTIEL INCISION – is a curve transverse incision across the lower abdomen and within or superior to the hairline of the pubis.

-its primary used is for an abdominal hysterectomy and cesarean section.

6. INGUINAL INCISION (LOWER OBLIQUE) – extends from the pubic tubercle to the anterior crest of the ilium, slightly above and parallel to the inguinal crease.

-incision provides access to the cremaster muscle; inguinal canal, and cord structures

- use for inguinal herniorrhaphy

BILIARY TRACT PROCEDURES: GALLBLADDER – is located in the right upper quadrant in a fossa under and

immediately adjacent to the right lobe of the liver. - Is a thin-walled sac and has a normal capacity of 50-75 ml of the bile.

- BILE – is secreted by the hepatic cells enters the intrahepatic bile ducts and progresses to the common bile duct.

- Not needed for digestion, bile is diverted through the cystic duct into the gallbladder, where it is stored. When the bile is needed, the gallbladder is contracts and empties bile into the cystic duct; bile flows into and through the common duct into the duodenum.

GALLSTONES – are concretions of elements of bile, particularly cholesterol (about 50%), found in the gallbladder in any portion of the extrahepatic biliary duct system.

-BROWN STONES- usually fatty acids.

-BLACK STONES- comprises of inorganic salts.

- incidence of gallstones, referred to as CHOLELITHIASIS, increase with age, more prevalent in women and in persons who are obese.

CASES NEEDS SURGICAL PROCEDURE - Acute or chronic inflammation of the gallbladder

- Common dust stones (choledocholithiasis)

- Carcinoma

- Congenital absence of bile ducts (biliary atresia) COMPLICATIONS: - Hemorrhage

- Injury to the extrahepatic biliary duct system

- Peritonitis – BECAUSE OF SPILLING OF BILE IN THE PERITONEAL CAVITY.

DIAGNOSTIC PROCEDURES: 1. Ultrasonography, nuclear imaging (hepatic intraductal assay (HIDA scan) and computed

tomography (CT) scanning.2. Oral and intravenous (IV) cholecystography – visualization of the gallbladder in the

initial evaluation of patients with biliary symptoms.3. Endoscopic retrograde cholangiopancreatography – identify stones, tumors, inflammatory

lesions or an obstructions,4. Flexible fiberoptic duodenoscope – introduced with the patient under IV sedation and

with the use of topical anesthetic to control the gag reflex- Dye is injected to opacify the entire biliary tract and pancreatic duct under

fluoroscopy.- ENDOSCOPIC PAPILLOTOMY

- PERCUTANEOUS TRANSHEPATIC PUNCTURE

- CHOLANGIOGRAM with the injection of the contrast medium dye.

CHOLECYSTECTOMY – is a surgical removal of the gallbladder, the most common procedure performed on the biliary tract

It is performed to relieve the gastrointestinal distress common in patient with acute and chronic cholecystitis (with or without gallstones)

Also removes a source of recurrent sepsis OPEN CHOLECYSTECTOMY – a patient is placed on supine

position

-RUQ may be slightly elevated on a gallbladder rest or pillow after the induction of general anesthesia.

-TRENDELENBURG POSITION – so the abdominal viscera gravitate downward, away from the surgical area.

OPEN ABDOMINAL CHOLECYSTECTOMY – the gallbladder is usually exposed through a right subcostal incision (Kocher incision) that may be extended over to the midline at the level of the xiphoid process. The incision should be adequate for good exposure of the gallbladder and the bile ducts.

-Laparotomy packs are used to wall off the surrounding organs for exposure.

-Bilious contents of the gallbladder may be aspirated to prevent bile from spilling into the peritoneal cavity – a potential source of peritonitis.

-some surgeons use ESU and/or neodymium :yttrium aluminum garnet (Nd:YAG) or holmium (Ho): YAG laser for sharp dissection and coagulation. Stones removed as part of the specimen should be sent to the pathology department for analysis and documentation.

-If bile leakage or hemorrhage has been excessive - SUMP DRAIN OR CLOSED WOUND SUCTION DRAIN may be placed in the subhepatic space and brought out a stab wound after intraabdominal irrigation.

LAPAROSCOPIC CHOLECYSTECTOMY – patient is supine in a slight to moderate reverse Trendelenburg position.

A rigid fiberoptic laparoscope is inserted through a sheath into the peritoneal cavity.

The location of the puncture sites will vary according to patient size and surgeon preference.

A camera attached to the laparoscope allows the surgeon to view the manipulation of instruments through the sheath of these trocars.

After careful dissection, the surgeon ligates and divides the cystic duct and artery with suture loops or clips.

COMMON DUCT EXPLORATION - Concomitant exploration of the common bile duct is often but not routinely

performed during cholecystectomy.- Palpable stones, jaundice with cholangitis and dilation of the common bile duct are

indications of exploration.- T – tube drain may be inserted to stent the duct and provide postoperative drainage.

INTRAOPERATIVE CHOLANGOGRAMS, X ray films are obtained during either open abdominal or laparoscopic procedures.- To check for patient position, scout films should be obtained when the patient is

initially positioned on the operating bed – before the procedure is started. - The peri-operative nurse should assess the patient for allergies or sensitivities to

contrast media and should ensure that the operating bed has a radiographic top or can be equipped for X-rays studies and fluoroscopy.

- CHOLANGIOGRAMS – are obtained after the gallbladder is removed or before the cystic duct and artery are ligated.

- A radiopaque contrast medium, usually Diatrizoate sodium (Hypaque or Renografin), is injected into the cystic duct or common bile duct with a 50 – ml syringe.

ULTRASONOGRAPPHY – a non invasive technique, takes less time and does not have the radiation hazards of intraoperative cholangiograms.

To enhance the transmission of ultrasound waves, the abdominal cavity is irrigated with warm normal saline solution.

Gallstones appear as bright echoes, often with acoustic shadow. CHOLEDOCHOSCOPY – intraoperative biliary endoscopy provides image transmission

and illumination, thus allowing the surgeon visual guidance in exploring biliary system. Intrahepatic and extrahepatic bile ducts can be visualized with the

flexible fiberoptic choledoscope introduced into the common duct To provide distention of the biliary duct, normal saline solution

must continuously flow to the irrigation channel. CHOLELITHOTRIPSY - is a non invasive procedure in which high energy shock

waves are used to fragment cholesterol gallstones. The procedure is performed under IV sedation or General

anesthesia. The patient is placed In prone position but also be in the supine

and lateral position on a lithotripter table; or submerged in a water bath

The shock waves are synchronized with the R waves of the patient’s cardiac rhythm, which is monitored by ECG to avoid dysrythmias.

This passage may be aided by oral administration of Deoxycholic acid (Ursodiol) taken daily after lithotripsy to dissolve the fragments.

CHOLEDOCHOSTOMY AND CHOLEDOCHOTOMY o CHOLEDOCHOSTOMY – a T-tube drain is used to drain the common bile duct

through the abdominal wall.o A CHOLEDOCHOTOMY is the incision of the common bile duct for the

exploration and removal of stones.o Intraoperative cholangiograpphy may be performed before and after exploration

and/or stone removal. The duct is irrigated after calculi are removed. Patency of the duct and of the ampulla of Vater is investigated, often through a choledochoscope.

o If a neoplasm is found during exploration, respectability is determined; many

tumors of the liver or pancreas are inoperable.

Cholecystodoudenostomy and cholecystojejunostomy -Either a cholecystoduodenostomy or cholecystojejunostomy is performed to relieve an obstruction in the distal end of the common duct.

-Through anastomosis, these procedures establish continuity between the gallbladder and either the duodenum or jejunum. Careful evaluation precedes the surgical procedures. - Cholecystoduodenostomy and cholecystojejunostomy are bypass procedures to avoid further obstruction jaundice, but they do not solve the problem. -Common causes of the obstruction are calculi, stricture of the duct, or neoplasm of the duct, ampulla of Vater, or pancreas.

Choledochoduodenostomy and choledochojejunostomy

-Choledochoduodenostomy and choledochojejunostomy are side-to-side anastomosis between the duodenum or jejunum and the common duct.

-These procedures are carried out for difficult or recurrent biliary or pancreatic obstruction as a result of benign or malignant disease.

LIVER PROCEDURES:

-the liver is the largest gland in the body, is divided into left and right segments (or lobes) and is located in the upper right abdominal cavity beneath the diaphragm.

-GLISSON CAPSULE – a tough fibrous sheath, completely covers the organ. the tissue within this capsule is very friable and vascular.

-HEPATIC ARTERY – a branch of the celiac axis, maintains the arterial supply.

-PORTAL VEIN – the blood from the stomach, intestines, spleen and pancreas is carried to the liver.

FUNCTIONS:

Forming and secreting bile which aids digestion. Transforming glucose into glycogen which it stores Helping to regulate blood volume. Responsible for the metabolic functioning of the body Metabolizes fats, proteins and carbohydrates Synthesizes cholesterol Excretes bilirubin Secretes hormones

-this organ is remarkable regenerative capacity and up to 80 % of it may be resected with little or no alteration in hepatic function.

-ASCITES may result from impaired liver function.

LIVER NEEDLE BIOPSY – a percutaneous needle biopsy may help establish a diagnosis a liver disease.

o Because the procedure is performed with local anesthesia, moderate sedation or

monitored anesthesia care (MAC), the patient should be instructed to take several deep breaths and then hold his or her breath and remain absolutely still while the needle is inserted.

o Failure of the patient to cooperate can cause needle penetration of the diaphragm

or hepatic injury and result in hemorrhage, a serious compliucation. Leakage of bile into the abdominal cavity may produce chemical peritonitis, an additional hazard.

o A Franklin-Silverman or Tru-cut biopsy needle is introduced into the liver via a

transthoracic intercostal or transabdominal subcostal route.o The needle is rotated to separate a small core of tissue, and it is then withdrawn to

remove the specimen.o As soon as the needle is removed, the patient is told to resume normal breathing

and assisted to turn onto his right side to compress the chest wall at the penetration site and prevent the seepage of bile or blood.

o PT is checked before test.

HEPATIC RESECTION -vital organ – entire liver can’t be removed (transplant)

PORTOSYSTEMIC SHUNTS -Portal HPN, bleeding esophageal varices, massive GI bleeding-To decompress portal venous system – splenorenal shunt

SPLENIC PROCEDURES

Splenectomy – the most common reason for removal of the spleen is hypersplenism – overactivity that causes a reduction in the circulating quantity of red cells, white cells, platelets or a combination of them,

-due to hypertension, over activity – causes a reduction in circulating RBC, WBC, platelets, whole blood transfusion

- post op meds – steroids, hemorrhage is a fatal complication & infection

Splenorrhaphy PANCREATIC PROCEDURES - endocrine & exocrine gland

- Islets of Langerhans – insulin & glucose

- CHO metabolism

- Acini – exocrine – pancreatic juice – neutralizes stomach acid

Pancreaticojejunostomy - Anastomosing a loop of the jejunum (roux-en-y loop) to the pancreatic duct.

- Hemorrhage and leakage of bile are complications to be avoided Pancreaticoduodenectomy (Whipple’s Procedure) - carcinoma of the head of pancreas f the ampulla of vater

Pancreatectomy – distal tail is resected to the head of the pancreas.

ESOPHAGEAL PROCEDURES

Esophageal Hiatal Herniorrhaphy • esophagitis, bleeding, stenosis, sphincter incompetence• esophageal varices. SBT – Sclerosing Agent Pre –Op

Esophagogastrectomy • portion of esophagus & proximal stomach are resected due to malignant • tumors• dumping syndrome post-op

Kidney Transplant irreversible kidney failure immunosuppressive lifetime (recipient) screening for donor ABO, histocompatibility 30-60 min (kidney must be cooled after cessation of renal perfusion) Pre op

• Histocompatibility • Dialysis• Reverse Isolation

Post op • assess kidney function (may return immediately after surgery or maybe delayed a

few days)• maintain protective isolation• monitor s/sx of organ rejection• dialysis• semifowler’s • output – bloody to pink initially return to yellow w/in days to weeks (if clot

occurs notify the doctor)

University of Perpetual Help System –JONELTA

General Mariano Alvarez, Cavite

ABDOMINAL AND INTESTINAL SURGERY

Submitted to:

Mrs, Juliana Sales, RN,MAN

Clinical Instructor @ Batangas Provincial Hospital

Submitted by:

Tan, Abigail E.

Taneza, Alco Jopat

Toledo, Kathleen

Umandap Aldrin

BSN III – E (GROUP 17)

BATCH 2012