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General Surgery
This section is divided into three parts:
• Abdominal wall procedures
• Abdominal contents procedures
• Breast procedures
Abdominal Wall Surgeries
Surgeries of the abdominal wall are all types of herniorrhaphy. As you have probably deduced from your past studies and your reading of Chapter 1: Medical Terminology, this term means “suturing of a hernia”—hernia repair. A hernia is a protrusion of an organ through a weakened spot in the abdominal wall nearby; the defect may be congenital or acquired (usually as a result of blunt trauma) (Fig. 7.1). There are several kinds of herniorrhaphy procedures; they may be performed laparoscopically or as open surgeries.
Procedures
• Direct inguinal hernia repair
• Indirect inguinal hernia repair
• Pantaloon hernia repair (repair of direct and indirect hernias at the same site in the same surgery)
• Hiatal hernia repair
• Incisional hernia repair (a.k.a. ventral hernia repair)
• Incarcerated (a.k.a irreducible) hernia repair
• Strangulated hernia repair
Basic Laparoscopic Equipment Required
• Light cord
• Camera
• Insufflation tubing (for introduction of CO2 gas to induce pneumoperitoneum)
• Trocars (surgeon’s preference as to type)
• Laparoscopy instruments
• General surgery major soft instruments
FIG. 7.1 Common types of abdominal hernias. A, Umbilical hernias result from a weakness in the abdominal wall around the umbilicus. An incisional hernia is herniation through inadequately healed surgery. In a femoral hernia, a loop of intestine descends through the femoral canal into the groin (femoral means “pertaining to the thigh”). B, Inguinal hernias are of two types. A direct hernia occurs through an area of weakness in the abdominal wall. In an indirect hernia, a loop of intestine descends through the inguinal canal, an opening in the abdominal wall for passage of the spermatic cord in males, and a ligament of the uterus in females. (From Leonard PC: Quick & easy medical terminology, ed 8, St Louis, 2017, Elsevier.)
Other Instrument/Equipment Required
• General surgery major soft tissue instrumentation (if incision is extended or any bowel is involved)
• Synthetic mesh (placed, in most procedures, over the defect; may or may not be sutured or stapled into place)
• Electrosurgical unit
• Harmonic scalpel (may be needed)
Basic Anatomy Involved
The surgeon must make his or her way through quite a few layers of abdominal wall (Fig. 7.2).
• Skin
• Fascia of Camper (superficial fatty layer of the subcutaneous tissue)
• Fascia of Scarpa (deep membranous layer of the subcutaneous tissue)
• External oblique
• Internal oblique
• Transverse abdominis muscle
• Endoabdominal fascia
• Extraperitoneal fat
• Parietal peritoneum
Additional Facts to Remember
• A Penrose drain is used to retract the spermatic cord in male patients.
• Direct and indirect inguinal hernia repairs both involve mesh repair with sutures or staples, as does incisional/ventral hernia repair.
• Hiatal hernia repair (laparoscopic Nissen fundoplication) may be converted to laparotomy if:
• The patient is obese
• The patient has a short esophagus
• The patient has a history of surgery in the upper abdominal area
• Two different laparoscopic approaches are used to correct direct inguinal hernia:
• TAPP (transabdominal preperitoneal procedure), in which pneumoperitoneum is established
• TEP (total extraperitoneal procedure), in which a balloon expander is inserted into the incision and used to instill air or normal saline solution (no pneumoperitoneum)
Mapping
Here’s how hernia procedures look once they’ve been mapped:
Surgical Mapping
Indirect inguinal hernia (congenital)
| Instruments | Important Anatomy Involved | Pathophysiology |
General surgery minor instruments Soft tissue/laparoscopic instruments | Peritoneal sac protrudes through internal inguinal ring and passes through inguinal canal; scrotum may be involved | Congenital defect in fascial floor of inguinal canal |
| Microbiology/Wound Classification | Skin Prep/Incision/Patient position | Pharmacology |
| Class I (clean) | Prep: midchest to pubis symphysis (may be extended to midthigh) Incision: oblique Position: supine | Antibiotic irrigation
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