Chapter 23: General Surgery

What does a midline incision expose?

- lower esophagus - stomach - small intestine - liver - biliary system - spleen - pancreas - proximal colon

What are the types of region-specific abdominal incisions?

- midline incision - paramedian incision - sub costal incision - flank incision - inguinal incision - McBurney incision - Rocky Davis - mid abdominal transverse - lower transverse incision (Pfannenstiel)

What are some functions of the muscles and fascia of the abdominal wall?

- protect the abdominal viscera - move the upper body in flexion and rotation - assist in respiration - assist in the "bearing down" during defecation and childbirth

What are the functions of the abdominal peritoneum?

- protects the viscera in the abdomen - secreted serous fluids, allowing abdominal structure to slide over each other easily

Which tissue layers are involved in a paramedian incision?

- skin - subcutaneous fat - anterior rectus muscles - rectus fascia - abdominal peritoneum

What tissues are involved in an inguinal incision?

- skin - subcutaneous fat - fascia - muscle - ligaments - peritoneum

Which tissues are involved in a McBurney incision?

- skin - subcutaneous fat - fascia - oblique and transversalis muscles - abdominal peritoneum

What tissues are involved in a lower transverse abdominal (Pfannenstiel) incision?

- skin - subcutaneous fat - rectus fascia - rectus muscles

Which tissues are involved in a subcostal incision?

- skin - subcutaneous fat - rectus muscles - fascia - abdominal peritoneum

Which tissues layers are involved in a midline incision?

- skin -subcutaneous fat - fascia (linea Alba) - abdominal peritoneum

Procedures for a TEP repair

1. A perimbilical incision is made through the rectus sheath 2. Tissues are dissected manually and then retracted. 3. A balloon tissue expander is introduced 4. The preperitoneal space is inflated, and the expander is removed. 5. A balloon trocar is inserted to seal the space 6. Two additional 5-mm ports are created. 7. The direct or indirect hernia is reduced, and polypropylene mesh is secured over the defect. 8. The wounds are closed as for a transabominal preperitoneal (TAPP) procedure

Procedures of a TAPP repair

1. Pneumoperitoneum is established, and trocars are inserted into the abdomen. 2. A transverse incision is made above the direct hernia space. 3. The weakened area in the pelvic floor is reinforced with mesh. 4. The peritoneum is closed. 5. Pneumoperitoneum is released, and the port incisions are closed.

Procedures for repair of an incisional or ventral hernia

1. The abdominal scar is removed and the edges of the previous incision are trimmed 2. Old sutures are removed 3. Abdominal adhesions are separated from the viscera and the interior abdominal wall 4. Synthetic mesh is secured over the abdominal defect 5. Al layers of the abdominal wall are closed

Procedures for an open repair of a femoral hernia

1. The groin is incised on the affected side 2. The hernia sac is identified and opened 3. The sac is ligated and removed 4. Synthetic mesh is secured over the defect 5. The wound is closed in layers as for an inguinal hernia

Procedures for umbilical hernia repair

1. a periumbilical incision is made 2. the linea alba defect is identified 3. the defect is dissected free of any tissue and the muscuofascial margins are idenified 4. the defect is repaired with sutures or mesh 5. the wound is closed

Procedures of an open repair of an indirect inguinal

1. a right or left inguinal incision is made 2. the layers of the abdominal wall are incised, and the edges are retracted 3. the spermatic cord is dissected from preperitoneal fat and other surrounding tissue 4. the spermatic cord is retracted with a small Penrose drain 5. the hernia sac is dissected from the cord and opened. The contents are pushed back into the abdomen. 6. The hernia sac is ligated with ties or a purse-string suture. 7. A synthetic mesh patch is sutured into place over the defect. 8. The abdominal wall is closed.

What is used to close the fascia during an indirect inguinal hernia repair?

2-0 nonabsorbable or absorbable synthetic sutures

What is used to close the subcutaneous tissue during an indirect inguinal hernia repair?

2-0 or 3-0 absorbable sutures

Wire localization

A biopsy procedure in which a hook wire is inserted under fluoroscopy into tissue suspected of s being cancerous.

Rectus Sheath

A broad fascial layer that extends across the abdomen without interruption

Morbid obesity

A condition in which the patient's body mass index (BMI) is 40 or higher, and the individual is at least 100 pounds (45 kg) over the ideal weight despite aggressive attempts to lose weight.

Friable

A descriptive term for tissue that means fragile and easily torn, and may bleed profusely; example: liver and spleen

Hook wire

A device used to pinpoint he exact location of a nonpalpable mass detected during a mammogram. Fine wire inserted into the mass during he examination, and the tissue around the needle is removed for pathological examination and definite diagnosis

Cirrhosis

A disease of the liver in which the tissue hardens and the venous drainage becomes blocked. Usually caused by chronic alcoholism but may result from other disease conditions

Skin flap

A flap is created by incising he skin and cutting it away from the underlying tissue to which it is attached. Can be increased in size or "raised" as it is enlarged by dissection

Nasogastric (NG) tube

A flexible tube inserted through the nose and advanced into the stomach. Used to decompress the stomach or to provide a means of feeding the patient liquid nutrients and medication

Billroth I procedure

A gastroduodenostomy, or surgical anastomoses, of the stomach and the duodenum

Billroth II procedure

A gastrojejunostomy, or surgical anastomoses, or the stomach and the jejunum

Femoral hernia

A hernia arising from a weakness in the transversalis fascia below the inguinal ligament

Strangulated hernia

A hernia in which abdominal tissue has become trapped between the layers of an abdominal wall defect. Tissue usually becomes swollen as a result of venous congestion.

Strangulated hernia

A hernia in which abdominal tissue has become trapped between the layers of the abdominal wall defect; tissue usually becomes swollen as a result of venous congestion

Indirect inguinal hernia

A hernia in which abdominal viscera slides into the inguinal canal from the deep inguinal ring; herniated tissue may extend through the superficial ring in the spermatic cord into the scrotum or labia

Exploratory laparotomy

A laparotomy performed to examine the abdominal cavity when less invasive measures fail to confirm a diagnosis

Bowel technique

A method of preventing cross-contamination between the bowel contents and the abdominal cavity

Paramedian (upper and lower) incision

A muscle-splitting incision; less painful than a subcostal muscle-cutting incision for access to the upper quadrants

Mastectomy

A procedure in which breast tissue, including the skin, areola, and nipple, is removed, but the lymph nodes are not removed

Sentinel lymph node biopsy (SLNB)

A procedure in which one or more lymph nodes are removed to determine whether a tumor is metastasized. Other lymph nodes may be removed periodically to determine whether metastasis had occurred

Laparotomy

A procedure in which the abdominal cavity is surgically opened.

Subcutaneous mastectomy

A procedure in which the breast is removed, but the skin, nipple, and areola are left intact; also called lumpectomy

Modified radical mastectomy

A procedure in which the entire breast, nipple, and areole region are removed. Lymph nodes also are usually removed

Hernia

A protrusion of tissue through a defect or weakness in the abdominal wall; most common pathology of the abdominal wall, can also occur along the linea Alba, umbilicus, and femoral regions

Technetium-99

A radioactive substance used to identify sentinel lymph nodes

Linea alba

A strip of a vascular tissue that follows the midline and extends from the pubis to the ciphoid process; extends the full length of the midline

Abdominal peritoneum (parietal peritoneum)

A strong serous membrane that lines the abdominal cavity

-ostomy

A suffix that refers to an opening between two hollow organs; for example, gastroduodenostomy, a surgical procedures that joins the stomach and the duodenum

Gastrostomy

A surgical opening through the stomach wall connecting to the outside of the body or another hollow anatomical structure

Anastomosis

A surgical procedure in which two hollow structures are joined

Ostomy

A technique in which a new opening is made between w tubular structure such as the intestine or ureter and the outside of the body or another hollow structure or organ

Stoma appliance

A two- or three-piece medical device used to collect drainage from a stoma. The appliance is attached to the patient's skin and completely covers the stoma. This allows free drainage into a collection device or bag

Ventral hernia

A weakness in the abdominal wall, usually resulting in protrusion of abdominal viscera against the peritoneum and abdominal fascia

Umbilical hernia

Abdominal wall defect occurring in the linea Alba at the umbilical ring seen in infants and adults

Mesentery

An extension of the peritoneum that attaches to the posterior abdominal wall and fans out to cover the small intestine

Stoma

An opening created in a hollow organ structure or organ and sutured to the skin to drain the organ's contents; may be temporary or permanent method of bypass

Segmental resection

Anatomical resection of the liver in which segments divided by specific blood vessels and biliary ducts are removed

Greater omentum

Another extension of the serous membrane covering the stomach, duodenum, and part of the colon; often referred to as peritoneal reflections

What does a McBurney incision expose?

Appendix

What is made of synthetic material similar to suture?

Biosynthetic mesh

What is used to repair defects in the fascia?

Braided synthetic suture and surgical mesh; monofilament may also be used

What may cause weakness in the wall of the abdomen?

Congenital anomaly, previous surgery, or injury

Pelvic cavity

Contains structured of the reproductive, genitourinary, and lower GI systems

Abdominal cavity

Contains the abdominal viscera (organs)

Retroperitoneal cavity

Contains the kidneys, adrenal glands, and ureters

Which hernia is usually acquired in older men?

Direct inguinal hernia

Esophageal varices

Distended veins of the esophagus, caused by advanced liver disease. Occurs as a result of portal vein obstruction arising from fibrosis of the liver. May bleed profusely

Which hernia occurs mainly in women and may require surgery to prevent tissue incarceration?

Femoral hernia

What may be inserted before surgery to decompress the bladder during repair of an inguinal or a femoral hernia?

Foley catheter

_____ may be inserted before surgery to decompress the _____ during repair inguinal or a femoral hernia.

Foley catheter; bladder

Quadrants

Four major sections of the abdomen; also called landmarks; often mentioned as the general location of a medical finding or anatomical structure.

What type of anesthesia is commonly used in hernia repair procedures?

General or spinal

Which organs are located in the mediastinum?

Heart Trachea Right and left bronchi Esophagus Thymus gland Aortic arch and thoracic aorta Venue cavae Lymph nodes & thoracic duct

Incarcerated hernia

Herniated tissue that is trapped in an abdominal wall defect; requires emergency surgery to prevent ischemia and tissue necrosis

Body image

In psychology, the way a person sees himself or herself through the eyes of others.

Lower transverse abdominal (Pfannenstiel) incision

Incision follows the natural skin folds to achieve cosmetic closure; it is very strong and offers good exposure to the pelvic contents

Inguinal (oblique)

Incision is used to gain access to the inguinal repair; also may be used for inertial access to the spermatic cord

McBurney incision

Incision made on the right side, at an oblique angle, in the flank below the umbilicus; it is a muscle-splitting incision and offers only limited exposure

Midline incision

Incision made through the skin, subcutaneous fat, and the linea alba

Subcostal incision

Incision that follows the lower rib margin in a semi curved shape; it is painful postoperatively

Which hernia may require mesh reinforcement to bridge and strengthen the tissue edges?

Incisional hernia

In which surgical procedure does the surgeon incise the skin over the groin using the skin knife?

Indirect Inguinal Hernia

Which hernia is usually caused by a congenital weakness in the inguinal ring, and may require surgery?

Indirect inguinal hernia

Are infected abdominal wounds closed?

Infected abdominal wounds are generally not closed beyond the fascial layer, however heavy monofilament synthetic retention suture may be placed behind the line of incision

What set is used for procedures involving the abdominal wall?

Laparotomy set

Subcutaneous

Layer that lies directly under the skin; composed of lobulated adipose (fat) and varies in thickness from 1/4" to more than 8"

What are the nine regions of the abdomen?

Left and right rib Left and right flank Left and right inguinal area Epigastric region: upper abdomen Umbilical region: area near the umbilicus Hypogastric region: lower region

LLQ

Left lower quadrant

What organ/organs are located in the left pleural cavity?

Left lung

LUQ

Left upper quadrant

Which organs are located in the RUQ?

Liver Gallbladder Colin Portions of the small intestine

Biosynthesis mesh

Made of synthetic material similar to suture

What instrument is used to dissect the hernia sac away from the cord?

Metzenbaum scissors

What does an inguinal (oblique) incision expose?

Muscles and fascia of the inguinal abdominal wall, spermatic cord, inguinal ring, abdominal ring, inferior epigastric artery and vein

Longitudinal rictus muscles

Muscles attached from the pubis to the fifth, sixth, and seventh costal (rib) cartilages

Abdominal wall Gastrointestinal (GI) system Binary system (gallbladder and associated structures) Spleen Pancreas Hepatic system Breast

Organs and organ systems involved in general surgery

Inguinal canal

Originates at the opening in the transversalis fascia at the deep inguinal ring and continues to the superficial inguinal ring; splits between the muscle layers near the inguinal ligament

A ____ is usually measured and cut during surgery, although _____ patched are available.

Patch; precut

Direct inguinal hernia

Protrusion of abdominal or inguinal tissue directly through the transversalis fascia

Incisional hernia

Protrusion of abdominal tissue through one or more abdominal layers; results from a previous abdominal incision that failed to heal completely or later broke down because of obesity, infection, or disease

Spigelian hernia

Rare hernia occurring between the transverse abdominis and rectus muscles

RLQ

Right lower quadrant

Which organ/organs are in the right pleural cavity?

Right lung

What does the thoracic cavity contain?

Right pleural cavity Mediastinum Left pleural cavity

RUQ

Right upper quadrant

What does a paramedian incision expose?

Right: biliary system, pancreas Left: spleen, sigmoid colon

What does a subcostal incision expose?

Right: biliary system, spleen Left (chevron): liver transplantation

Remodeling phase of healing

Scar tissue fills the spaces

What happens during the remodeling phase of healing?

Scar tissue fills the spaces of the mesh

Posterior abdominal peritoneum

Separated the anterior abdominal cavity from the Retroperitoneal cavity

What are the tissues of the abdominal organs?

Skin Subcutaneous fatty tissue ("sub-cu") Fascia Muscle Peritoneum

What are the structures contained in the spermatic cord?

Spermatic fascia Cremaster muscle Genitofemoral nerve Ductus deferens Lymph vessels Testicular vein and artery

Which hernia is rarely diagnosed but is seen occasionally during surgery for other reasons?

Spigelian hernia

Which organs are located in the LUQ?

Stomach Pancreas Spleen Portions of the small instestine Kidneys Adrenal glands Descending aorta Ureters

Which hernia is an emergency condition requiring surgery to release the tissue and prevent each emus and necrosis?

Strangulated/ incarcerated hernia

What position is the patient in when undergoing surgical procedures of the abdominal wall?

Supine

What is used for most hernia repairs?

Surgical mesh

Lobectomy

Surgical removal of one or more anatomical sections of the liver

Hesselbach triangle

The area bounded by the refute abdominis muscle, the inguinal ligament, and the inferior epitgastric vessels; larger in males than in females

Which regions do hernias most often occur?

The inguinal and femoral regions

Bariatrics

The medical and surgical treatment of morbid obesity

Continguous

The muscles cross each other and attach at different levels in the fascia; examples: fatty and skin layers

Viscera

The organs or tissue of the abdominal fascia

What corresponds to the higher incidence of inguinal hernias in males?

The size of the Hesselbach triangle

Are infected abdominal wounds closed?

They are generally not closed beyond the fascial layer

Strangulated or incarcerated hernia

Tissue protruding from the hernia may become swollen and squeezed; may result in local ischemia or other complications

What is the principle of mesh repair?

To provide a bridge of strong material over the abdominal wall weakness and release tension on the tissue edges during repair and healing

Reduce

To replace or push herniated tissue back into its normal anatomical position

What is the surgical goal of an open repair of an indirect inguinal hernia?

To restore strength to the inguinal floor and prevent the abdominal viscera from entering the inguinal canal

What two techniques are currently used for the laparoscopic approach to a direct inguinal hernia?

Transabdominal preperitoneal (TAPP) laparoscopy Total extraperitoneal (TEP) surgery

What are the three flanking muscles? Where are they located?

Transverse external oblique, internal oblique, and transverse abdominis muscles; lateral to the rictus muscles

Which hernia rarely requires surgery?

Umbilical adults

Which organs are located in the pelvic cavity?

Ureters Uterus and adnexa (female) Prostate gland (male) Urethra Urinary bladder Sigmoid colon Rectum

What does a lower transverse abdominal (Pfannenstiel) incision expose?

Uterus, adnexa, bladder, access for cesarean section

indirect inguinal hernia

a hernia that protrudes into the membranous sac of the spermatic cord; usually due to a congenital defect in the abdominal wall

direct inguinal hernia

a hernia that results from weakness in the inguinal floor

Transabdominl preperitoneal (TAPP) laparoscopy

a pneumoperitoneum is created and the inguinal canal is entered via the abdominal cavity

hernia

a protrusion of tissue under the skin through a weakened area of the body wall

linea alba

a strip of avascular tissue that follows the midline and extends fro the pubis to the xiphoid process

Fistula

a tract or tunnel through the tissue that develops a lining of epithelium

fistula

an abnormal tract or passage leading from one organ to another or from an organ to the skin; usually caused by infection

Hesselbach Triangle

an area bounded by the conjoint tendon, inguinal ligament, and inferior epigastric vessels

McBurney incision

an incision in which the oblique right muscle is manually split to allow removal of the apendix.

Direct inguinal hernia

arises from a defect behind the superficial inguinal ring in the inguinal floor, through the transversalis fascia

What are used to repair defects in the fascia?

braided synthetic sutures and surgical mesh; monofilaments may also be used

Which is an acquired hernia that occurs most often in older men and becomes larger with age or obesity?

direct inguinal hernia

What type of anesthesia is commonly used during a hernia repair procedure?

general or spinal anesthesia

incarcerated hernia

herniated tissue that is trapped in an abdominal wall defect; requires emergency surgery to prevent ischemia and tissue necrosis

What is it called when a herniated tissue becomes trapped by the surrounding tissue?

incarcerated or strangulated hernia

What set is used for procedures involving the abdominal wall?

laparotomy set

A _____ is usually measured and cut during surgery, although precut ones are available.

patch

What is used to retract the spermatic vessels and vas deferens (spermatic cord)?

penrose drain

evisceration

protrusion of the viscera outside the body as a result of trauma or wound diruption

Evisceration

protrusion of viscera outside of the body

Laparoscopic direct hernia repair is the preferred technique to ______ herniated tissue and _____ the inguinal floor.

reduce; strengthen

Ventral hernia

refers to any hernia occurring in the abdominal wall, excluding the groin or inguinal area

Indirect inguinal hernia

results in protrusion of the abdominal viscera into the inguinal canal from the deep inguinal ring

What is used to close the skin during an indirect inguinal hernia repair?

staples or 3-0 or 4-0 nonabsorbable sutures

What position is the patient placed in for procedures of the abdominal wall?

supine position

What is used for most hernia repairs?

surgical mesh

Where do hernias most often occur?

the inguinal and femoral regions; may also occur along the linea alba umbilicus, or previous abdominal incision

incisional hernia

the postoperative herniation of tissue into the tissue layers around an abdominal incision; this may occur in the immediate postoperative period or later, after an incision is healed

Total extraperitoneal (TEP) surgery

the preperitoneal space is inflated with a balloon dissector, which expands the tissue planes.

What causes an umbilical hernia?

the result of a defect in the linea alba at the umbilical ring

Abdominal peritoneum

the serous membrane lining the walls of the abdominal cavity

What is the surgical goal of a femoral hernia?

to reduce abdominal tissue that has entered the femoral canal; the abdominal wall defect is closed to prevent recurrence

What is the surgical goal for an umbilical hernia repair

to repair an abdominal wall defect in the periumbilical region