Perioperative Case Management



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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


image

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)

image

FIG. 7.2 Layers involved in abdominal wall surgeries.


• 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

Direct inguinal hernia (acquired)












Instruments Important Anatomy Involved Pathophysiology

General surgery minor; instruments

Soft tissue/laparoscopic instruments
Hesselbach triangle (between rectus abdominis muscle, inguinal ligament, and inferior epigastric artery)
Heavy lifting

Chronic cough

Constipation











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

Lidocaine (before incision) or marcaine (post-op) or 50/50 combo

 


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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May 5, 2017 | Posted by in GENERAL SURGERY | Comments Off on Perioperative Case Management

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