Chapter 14: General Surgery; Short Answer: Incisions; Short Answer and Critical Thinking: Laparotomy

Assuming no one was relieved during the case, how many counts would you anticipate are made during the case?

3 minimum; an initial count, a count at the closure of the abdominal cavity, and then a count at the closure of the skin. If an emergency - 4 counts would be done as a precaution.

What type and size of suture is typically used for a subcuticular closure? What type of needle do you anticipate would be used?

4-0 Vicryl; Cutting needle

What precaution should be taken for each incision? A) Precaution for a median incision that will ensure no damage to the bladder or falciform ligament: B) Precaution for a right or left Kocher incision that will ensure no subsequent weakening of the abdominal musculature:

A) Peritoneum entered as a point closest to the umbilicus. B) The 9th dorsal nerve must be preserved.

Identify the incisions in Figure 14-1. (A-J)

A) Right upper paramedian B) Left lower paramedian C) Right subcostal D) Right midline transverse E) Pfannenstiel F) Upper longitudinal G) Lower longitudinal H) McBurney's I) Inguinal oblique (right) J) Right thoracoabdominal

F) The surgeon has transected the peritoneum and is ready to place a self-retaining retractor for a laparotomy; a large Bookwalter is not available and this is an emergency procedure. Describe how to pass the most likely self-retaining retractor.

Balfour is passed with blades of sufficient length to retract wound edges, then a bladder blade if needed.

An incision is made; describe the anticipated instrumentation to pass for the following events. (A-G) A) Time out has been completed and the incision is made with visual oozing of blood noted; what would you pass?

Hemostat

G) The patient is morbidly obese with a height of 5ft. and a weight of 200 lb. Anticipation requires planning, as you note this when the patient arrives in the operating room (OR). What type of instrumentation may be needed for emergency laparotomy surgery for patients who have a deep cavity?

Long/deep instrumentation

E) The surgeon has reached the level of the peritoneum and the earlier retractor is not providing adequate retraction; what instrument might be passed?

Longer/deeper retractor

C) A visible blood vessel has been exposed (ties are available); what would you pass?

Nonabsorbable tie

B) The initial oozing is controlled, and the surgeon is ready to dissect; what would you pass for dissection?

Pott Scissors

D) The tissue is deeper and retraction of about 1 1/2 inches of tissue is needed; what instruments might be passed?

Richardson retractor

Which incision is used most commonly for emergency surgery? Which incision is least likely to have an incidence of incisional herniation but a greater chance of infection or nerve damage?

Thoracoabdominal; Vertical/Paramedian