Important steps in common operations

• Correct patient

• Correct surgeon

• Correct anaesthetist

• Correct assistant

• Correct diagnosis?

• Correct and complete preoperative tests (e.g. FBC, U&E, ECG)

• ASA grading?

• Correct radiology?

• Group and save/cross-match/clotting

• Hepatitis B, C, HIV status known? MRSA?

• Informed consent

• Type of anaesthetic (general, regional block, local infiltration)

• DVT prophylaxis (stockings, LMWH)

• Site marked clearly by surgeon

• Correct operation?

• Position on table

• Skin preparation (NB allergies)

• Surgeon and staff protection

• Diathermy precautions

• Drapes

• Incision

• Detailed operative notes

• Detailed postoperative instructions to medical and nursing staff.

• Incision (midline, transverse, laparoscopic)

• Preliminary laparotomy, laparoscopy

• Determine operability, stage of disease

• Lateral to medial dissection (open procedure)

• Medial to lateral dissection (laparoscopic)

• Ligation of major vessels

• Radical excision of lymphatic vessels

• Division of terminal ileum, transverse colon

• Ensuring of good blood supply to cut ends

• Anastomosis of ileum to colon (sutures or staples)

• Close mesenteric defect

• Washout with cytocidals (water, Betadine)

• Closure in layers/mass

• No drain

• Return patient in satisfactory condition to recovery unit

• Postoperative instructions.

• EUA, sigmoidoscopy, proctoscopy and biopsy

• Identify track(s) using probes, dye or H₂O₂

• High or low?

• Relation to internal/external sphincter

• Low – lay open from external to internal opening

• Curettings to histology

• High – consider laying open lower track

• High – consider seton suture (tight/loose)

• Further options: Fibrin glue insertion, Fistula plug, Mucosal advancement flap

• AND SEEK SENIOR HELP IF IN DOUBT.

• Site incision according to operation

• Ribs are not counted until after muscle division

• Upper lobe fourth/fifth interspace, lower lobe sixth/seventh interspace

• Incision from midline skirting scapula to mid-axillary line

• Divide muscles (two layers) – preserve serratus anterior

• Count ribs, divide periosteum and strip with rougine

• Resect 2–3 cm of rib posteriorly

• Warn anaesthetist, open pleura along length

• Insert rib spreader

• Proceed to operation

• Close over two drains (apical and basal)

• Close intercostal layers

• Close muscle layers and skin

• Attach underwater drains and re-expand lung

• Return patient in stable condition to recovery.

• Expose hip joint (anterior/posterolateral)

• Open capsule and dislocate joint

• Remove femoral head at angle corresponding to prosthetic shaft

• Ream the femur with broaches

• Prepare acetabulum by excising all soft tissue

• Enlarge acetabulum to fit cup

• Drill keying holes to provide grip for cement

• Fit acetabular cup

• Insert femoral component into femur

• Reduce the joint

• Close wound in layers with drainage.

Identify structures in order as indicated by arrows:

• liver, gallbladder, right kidney

• oesophagus, fundus of stomach, spleen

• body of stomach, duodenum, pancreas, left kidney

• lesser sac, transverse colon

• small bowel, appendix, aorta, ureters

• ascending colon

• descending colon, sigmoid, upper rectum

• uterus, fallopian tubes, ovaries and bladder

• pouch of Douglas.

• Mark site of pterion burr hole after shaving (3 cm above mid-zygomatic point)

• Incise the scalp and use self-retaining retractor

• Free the pericranium

• Use Hudson brace with perforator

• Move perforator gently to engage outer table and proceed to turn

• Apply firm pressure to the head to prevent lateral movement

• Exchange perforator for burr when inner table has been reached

• Ensure burr hole is vertical

• Stop bleeding from diploe with bone wax

• If extradural haematoma is found, proceed to further burr hole to the limit of the haematoma

• Consider craniectomy

• Remove blood clot carefully, wash with saline

• Secure bleeding point on middle meningeal artery

• Check for subdural haematoma

• Meticulous haemostasis

• Close wounds.

• Skin crease incision

• Open external oblique

• Preserve ilioinguinal nerve if possible

• Identify sac and contents, spermatic cord in male

• Carefully separate cord from sac

• Avoid damage to vas and testicular artery

• Open sac; check viability of bowel/omentum

• Resect if necessary

• Reduce contents

• Perform herniotomy

• Attach mesh to transversalis fascia

• Close in layers.

• Check all instruments, cameras, insufflators, screens etc.

• Preset CO₂ insufflator to 13–15 mm

• Insert first port (Hasson technique/Veress needle)

• Laparoscopy, identify gallbladder, cystic duct and artery

• Beware anatomical variations

• Dissect Calot’s triangle, cystic duct and artery

• Operative cholangiogram (if indicated)

• Securely clip artery and duct

• Dissect gallbladder from liver bed (meticulous haemostasis)

• Remove gallbladder via epigastric port using a retrieval bag

• Repeat laparoscopy for damage/bleeding from other sites

• Drain optional

• Check port sites for bleeding

• Close all port site wounds carefully

• Return patient to recovery unit in a stable condition.

• Gridiron/Lanz incision

• Identify caecum/appendix

• If normal, examine small bowel for Meckel’s, Crohn’s disease

• If normal, inspect tubes/ovaries

• Deliver caecum/appendix

• Divide appendicular artery and appendix mesentery

• Clamp base of appendix

• Ligate base, remove appendix for histology

• Purse string to bury stump

• Irrigate pelvis and aspirate if peritonitis

• Close wound in layers – no drain.

• Upper midline incision

• Laparotomy

• Identify perforation

• Duodenal? Omental plug (mobilise omentum first)

• Gastric? Excise ulcer, send to pathology, close gastrotomy

• Meticulous lavage with saline

• Drain (optional)

• Close in layers.

• Laparotomy

• Identify pathology (stricture, perforation, tumour, Crohn’s)

• Identify arterial arcades

• Resect appropriate segment

• Avoid bowel spillage (use soft bowel clamps) Ensure good vascularity of cut ends

• No tension

• Anastomose ends (extramucosal interrupted using 2-O/3-O Vicryl)

• Start at mesenteric border

• Close mesenteric defect (avoid damaging arcades)

• Lavage with saline

• Close wound

• No drain.

• S-shaped incision behind the ear and down sternomastoid

• Expose the main trunk of the facial nerve

• Reflect the parotid tissue superficial to the facial nerve

• Follow the nerve and branches until parotid border is reached

• Meticulous dissection (ideally with nerve stimulator) Tie the parotid duct

• Remove the gland

• Meticulous haemostasis

• Drain

• Close wound.

• Expose common, superficial and profunda arteries

• Expose long saphenous vein (LSV) at termination

• Continue down the limb, isolating saphenous vein to knee

• Divide all LSV tributaries and free the vein

• Expose popliteal artery

• Detach the vein at this level and reverse

• Ensure adequate length of vein

• Decide upper and lower levels for anastomosis

• Make subcutaneous tunnel for LSV

• Give heparin

• Anastomose LSV to popliteal artery

• Check forward and back flow

• Anastomose LSV to common/superficial femoral artery

• Check arteriogram and flow

• Close wounds and check pulses.

• Midline incision

• Reflect root of mesentery to duodenojejunal flexure

• Identify neck of aneurysm and common iliac arteries (limited dissection)

• Give heparin and clamp aorta and common iliacs

• Incise aneurysm and oversew lumbar artery origins

• Oversew middle sacral artery and inferior mesenteric

• Inlay Dacron graft to upper end (beware renal artery origins)

• Test upper anastomosis

• Suture lower end to iliacs or bifurcation

• Check back bleeding and debris is flushed out before releasing clamps

• Close aneurysm sac

• Close wounds.

• Insert purse string around anus

• Incision as shown

• Deepen incision to reach coccyx

• Develop posterior plane to meet abdominal operator

• Deepen lateral dissection to include levators

• Anteriorly in male develop plane between rectum and prostate

• In female posterior wall of vagina may be included in specimen

• Meet perineal operator for lateral ligaments

• Deliver specimen through the perineum

• Ensure meticulous haemostasis

• Close the wound over an abdominal drain

• Deliver the patient in a stable condition to recovery unit.

• Full laparotomy, determine nature of pathology

• Consider resection and anastomosis with covering ileostomy

• Mobilise left colon to sacral brim

• Identify ureters, preserve spleen

• Ligate inferior mesenteric, preserve left colic artery

• Ligate inferior mesenteric vein

• NB: Radical excision if carcinoma

• Resect specimen (may be very difficult)

• Oversew/staple rectal stump

• Left iliac fossa trephine

• Construct colostomy

• Lavage with cytocidal agent

• Drain to pelvis

• Close wound.

• Mastectomy may be done at the same time

• Preoperative marking of skin paddle (different formats)

• Fashion skin paddle and define margin of latissimus dorsi muscle

• Inferior and medial border of muscle divided

• Dissect the latissimus dorsi from surrounding tissues

• Identify neurovascular bundle (deep surface) (separate axillary incision may be used)

• Transpose paddle to breast pocket.

• Transverse incision to include nipple

• Fashion skin flaps to incorporate the whole breast

• Avoid buttonhole injury to the skin

• Dissect breast from fascia over pectoralis major

• Meticulous haemostasis

• Irrigate with cytocidal solution

• Open the axilla through a separate incision

• Clean the axillary vessels taking all fat, lymph nodes and fascia

• Lateral thoracic vessels and intercostal brachial nerve are taken

• Avoid damage to brachial plexus and long thoracic nerve of Bell

• All nodes to the apex of the axilla are cleared

• Haemostasis

• Close both wounds over suction drains.

• Kocher’s incision

• Divide the strap muscles of the neck

• Divide and ligate the middle thyroid veins

• Draw down upper pole and identify superior thyroid vessels

• Ligate superior vessels and draw down upper pole

• Dissect lateral areolar tissue and identify inferior thyroid artery

• Identify recurrent laryngeal nerve (RLN)

• Tie inferior thyroid artery in continuity lateral to the RLN

• Divide inferior thyroid vein

• Mark line of section with haemostats

• Cut isthmus cleanly to trachea and dissect lobe free

• Remove lobe and oversew thyroid remnant to trachea

• Meticulous haemostasis

• Repair strap muscles

• Close wound over a drain.

For patients with respiratory distress in whom tracheal intubation has failed. It is a temporising measure, maximum duration 72 h (formal tracheostomy if continued surgical airway required) due to the danger of permanent laryngotracheal damage, particularly in children.

• Very brief sterilization/drape (e.g. chlorhexidine spray)

• Palpate the cricothyroid membrane (soft area just below the thyroid cartilage and just above the cricoid cartilage)

• Make a 2-cm transverse incision directly over the cricothyroid membrane (stabilising the trachea)

• Palpate the membrane directly and make a further 1-cm incision in the membrane itself

• Insert tracheal tube and secure to the skin (tape/suture)

• Connect to ventilator/ambubag.