Cholecystectomy Circumcision Thyroidectomy Appendicectomy Tracheostomy hydrocele repair Hernia repair Varicocele repair Varicose vein repair Parotidectomy mastectomy Incision & drainage of abscess Excision of lipoma, Excision of sebaceous cyst

1. Operative surgery
TONY 2010 MBBS 1

2. Contents
• Cholecystectomy
• Circumcision
• Thyroidectomy
• Appendicectomy
• Tracheostomy
• hydrocele repair
• Hernia repair
• Varicocele repair
• Varicose vein repair
• Parotidectomy
• Mastectomy
• Neck dissection
• Incision & drainage of abscess
• Excision of lipoma
• Excision of sebaceous cyst
TONY 2010 MBBS 2

3. Cholecystectomy
TONY 2010 MBBS 3

4. Cholecystectomy
• Indications
• Cholelithiasis with complications
• Biliary colic a/c & c/c cholecystitis,empyema ,mucocele
• Cholelithiasis in a
• DM ,immunosuppressed
• Hemolytic anemia
• Young individuals
• Carcinoma
• Choledochal cyst
• Ca head of pancreas in whipples
TONY 2010 MBBS 4

5. • Anaesthesia
• GA
• Position
• Supine trendelenberg position
• Pillow under the right lumbar & tilt to the left
• Skin preparation:
• Prepare the skin from nipple line to mid-thigh, drape to expose the right
upper quadrants
• Incision
• Kochers right subcostal Incision (muscle cutting incision)
TONY 2010 MBBS 5

6. Other less common incisions
• Midline incision
• Muscle is not cut
• ↓bld supply improper healing
• Paramedian incision
• Right upper quadrant transverse incision
• Heal easier
• Mayo robson incision
• Combination of medial half of kochers +paramedian incision
TONY 2010 MBBS 6

7. 2 methods
• Conventional /classic /retrograde(commonly done)
• From cystic duct to fundus
• Fundus first method
• From fundus to cystic duct
• Separate GB from liver bed & cover the raw area on liver by thin peritoneum
• Injury to CBD & rt hepatic A
TONY 2010 MBBS 7

8. Procedure
• Retract rectus abdominis laterally
• Open peritoneum
• Pack and retract bowel
• Identify GB at the tip of 9th costal cartilage
• Catch hold of fundus with sponge holding forceps
• Identify calots triangle
• Ligate cystic A & cystic duct close to the GB
• Separate the GB from liver
• Drain to prevent Waltmann Walter syndrome
TONY 2010 MBBS 8

9. TONY 2010 MBBS 9

10. Complications
• Haemorrhage
• Necrosis of right quadrant of liver (d/t rt hepatic artery is affected in
ligature)
• Injury to CBD
• Bile leak – walkmann waters syndrome
• May mimic MI
• Tachycardia
• Upper abdominal pain
• Lower chest pain
• Shock
TONY 2010 MBBS 10

11. Circumcision
TONY 2010 MBBS 11

12. Circumcision
• Indications
• Religious
• Phimosis paraphimosis
• Differentiated carcinoma prior to radiotherapy
• Cosmetic
• Anaesthesia
• LA in adults
• Ring block with out adrenaline
• GA in children
• Position of the Patient: Supine
TONY 2010 MBBS 12

13. Steps
• 2 forceps on either sides of 12 O clock position of foreskin
• Dorsal slit in 12 O clock position halfway to glans
• From there cut downward & laterally on either side till u reach frenulum (6 O clock)
• Tie frenular artery with U stitch cut vessel distal to ligature
• Stitch at 12,3,6& 9 o clock positions
• Ligate all bleeding points
• 4 forceps to hold each of stitches
• Suture b/w
• 12 & 3 ,
• 3& 6,
• 6 & 9,
• 9& 12
TONY 2010 MBBS 13

14. 4,Ligatting frenular A
2,Dorsal slit
3,Extend the incision
suturing TONY 2010 MBBS 14

15. Complications
• Infection
• Bleeding hematoma
• Injury to glans
• Delayed healing due to tension
TONY 2010 MBBS 15

16. Post op advices
• Handle 4 penis
• Apply ice cubes
• Urinate every 4 hours
• Full bladder can compress deep dorsal vein
TONY 2010 MBBS 16

17. Thyroidectomy
TONY 2010 MBBS 17

18. Thyroidectomy
• Indication
• Cosmetic
• Pressure symptoms
• Dyspnea dysphagia
• Malignancy
• Preparation of the patient
• Make the patient euthyroid
• To prevent thyroid storm/crisis
TONY 2010 MBBS 18

19. • Anaesthesia :
• GA
• Position
• Supine with neck extended with sand bag under shoulder (rose position)
• Clean and drape the area
• Incision
• Kochers collar incision
• 2 finger breadths above the suprasternal notch from posterior border of one
sternocleidomastoid to another
TONY 2010 MBBS 19

20. • Skin, superficial fascia containing platysma is cut upto investing layer
of deep fascia
• Flaps are raised
• Upper upto laryngeal prominence
• Lower upto suprasternal notch
• Investing layer of deep fascia is incised vertically
• Retract srap muscles laterally
• Cut them at upper 1/3rd (to prevent injury to ansa cervicalis)
• If thyroid is too large
• Muscles are infiltrated
• Retrosternal extension with impaction
TONY 2010 MBBS 20

21. • Identify the pedicles
1. Superior thyroid pedicle (sup throid A (branch of ECA )& V (drains in to IJV))
2. Middle pedicle (middle thyroid V only (drains in t IJV))
3. Inferior pedicle (inferior thyroid A only (thyrocervical branch of 1st part of
subclavian A))
• Ligate middle thyroid vein first
• Short vein drains into IJV (large vein) if missed torrential hge ))
• Ligate superior throid A & V separately & close to the gland
• Separately: If done together AV fistula can occur
• Close to the gland : to prevent injury to external laryngeal nerve
TONY 2010 MBBS 21

22. • Ligate inferior thyroid A close to the gland after identifying & safe
guarding recurrent laryngeal nerve
• To prevent loss of blood supply to parathyroids
• Sup parathyroid : by sup & inf parathyroid A
• Inf parathyroid : by inf parathyroid A only
• Identification of parathyroid
• Yellowish pink (peanut butter appearance) if devascularised become greyish
• Sinks in NS
• Position
• Sup parathgyroid : middle of superior & inferior throid A
• Inferior parathyroid : sup parathyroid & sup mediastinum
TONY 2010 MBBS 22

23. • Identification of RLN
TONY 2010 MBBS 23

24. • Transfix & Ligate thyroidima A,sup thyroid V ,4th thyroid v of kocher
• Thyroidectomy proper
• Total
• Subtotal
• Neartotal
• Wound closure:
• Reapproximate strap muscles and platysma
• Skin closure with subcuticular stitch
• Dressing
TONY 2010 MBBS 24

25. Complications
• Complications of anaesthesia
• Complications of Sx
• Hge
• injury to adjacent structures (trachea esophagus )
• Injury to RLN,ext LN,Sup LN parathyroid
• Postoperative
• Early
• Hematoma reactionary hge
• Late
• Recurrence
• Hypothyroidism
• Tetany
TONY 2010 MBBS 25

26. Appendicectomy
TONY 2010 MBBS 26

27. Appendicectomy
• Indications
• a/c appendicitis
• Recurrent appendicitis
• Carcinoid at the tip of appendix
• Contraindications
• Appendicular mass faecal fistula
• Position
• Supine
• Anaesthesia
• GA
• Spinal/epidural
TONY 2010 MBBS 27

28. • Preparation
• Cleaned with iodine & spirit
• Incision
• Muscle splitting incision
• McBurneys grid iron
• Most popular
• 6-8cm long at McBurneys point perpendicular to spinoumbilical line
• Lanz incision
• Curved transverse incision cosmetically better
• Right paramedian incision
• When diagnosis is doubtful
• Bikini incision
• Very low & very cosmetic
• Part of pfannensteil incision rt part
• Muscle cutting
• Rutherford Morrison incision
TONY 2010 MBBS 28

29. TONY 2010 MBBS 29

30. • Layers opened:
• skin
• two layers of subcutaneous tissue: Camper's, Scampa's..
• external oblique aponeurosis running downwards and medially.it is incised in
the direction of the fibres
• Internal and transverse abdominal muscles are split
• Peritoneum is opened
TONY 2010 MBBS 30

31. • Locate appendix using taenia coli
• Surgical procedure
• Appendix is gently held at mesoappendix by using Babcock's forceps and
blood vessels in the mesoappendix are divided.These include appendicular
artery, branch of ileocolic artery.Once the appendix is freed upto the base
(caecum), a purse string suture is applied all round appendix, taking bites
from caecum , using 2-0 atraumatic silk.
• Appendix is crushed at the base and is held 1cm above the crush. A tight silk
ligature is applied at the crushed site and appendix is cut in between.Stump is
cleaned with spirit.invaginated and purse string is tightened.This is called
burial of the stump (to prevent adhesions of exposed mucosa)
• Perfect haemostasis is obtained.
TONY 2010 MBBS 31

32. • Closure
• Peritoneum -continous 2-0 catgut/vicryl
• Split muscles -sutured together by a few interrupted suteres using chromic
catgut/vicryl
• External oblique is sutured with silk
• Subcutaneous fat is sutured with vicryl
• Skin with interrupted silk .Instead of catgut, 2-0 silk , 2-0 vicryl is being used
more often nowadays.
• Corrugated red rubber drain is not kept routinely unless there is gangrenous
appendicitis or a lot of pus in the peritoneal
TONY 2010 MBBS 32

33. • Postoperative
• Ryles tube aspn for 2 days
• IV fluids
• Appropriate Abx
• Suture removal 7-10 days
TONY 2010 MBBS 33

34. Complications
• Peritonitis
• From spread of infection
• Wound infection
• Intra abdominal abscess
• Fecal fistula formation
TONY 2010 MBBS 34

35. Tracheostomy
TONY 2010 MBBS 35

36. • Indication:
• Emergency:
• choking, stridor
• Coma severe barbiturate poisoning
• Foreign body
• Elective: Coma , tetanus, barbiturate,head injuries, pulmonary insufficiency
• Contraindications:
• Anaplastic carcinoma thyroid patients presenting with stridor due to infiltration of
growth into trachea.
• Anaesthesia: LA
• Position
TONY 2010 MBBS 36

37. TONY 2010 MBBS 37

38. TONY 2010 MBBS 38

39. Procedure:
• Incision:
• Tranverse curved incision 3-4cm at the level of 2nd tracheal ring.(horizontal)
• Vertical in emergency
• Dissection: Skin , subcutaneous tissue and deep fascia are incised.Isthmus of thyroid is separated.
• Procedure:
• A transversed curved cut is made at the level of 2nd tracheal ring, its edge is held by Allis forceps
and a small cuff of cartilage is removed. Cricoid hook can be used to stabilise the trachea (found
more usefull in children).
• Ligate anterr jugular vein ,isthmus of thyroid ,thyroidima
• A suitable sized tracheostomy is introduced within.
• The cuff of tracheostomy tube is inflated by using 2-5ml of air and is held in place by passing a
tape around the neck.
• Confirm the tube in the trachea not in the subcutaneous plane.
• Confirm air entry into both lungs.
TONY 2010 MBBS 39

40. • Post op Rx
• Suction of tracheostomy tube
• Regular dressing
• Humidification of air
• Check for air entry
• Inner tube cleaned in 3 hours outer tube in week ly
• Post op complication
• wound infection
• Air leakage
• Improper air entry
• cricoid stenosis
TONY 2010 MBBS 40

41. Hydrocele repair
TONY 2010 MBBS 41

42. • Indications
• Cosmetic
• Symptomatic
• Very large
• Anaesthesia
• LA or spinal
• Incision
• Paramedian incision on the side of hydrocele
TONY 2010 MBBS 42

43. • Structures cut
• Skin
• Superficial fascia with dartos muscle
• External spermatic fascia
• Dissect all around
• Study the tunica,size of the sac,thickness of the wall
• Make a stab incision & drain the fluid
TONY 2010 MBBS 43

44. Procedures
• Small sized & thin wall
• Plication of the sac }lords plication
• Large sac & thick wall
• Eversion of sac } jaboulays procedure
• Very large hydrocele
• Excision & eversion
TONY 2010 MBBS 44

45. • If the sac is small, thin and contains clear fluid, either
• Lord’s plication, i.e. tunica is bunched into a “ruff” by placing series of multiple
interrupted chromic catgut sutures so as to make the sac form a fibrous tissue which
is relatively avasular and so haematoma will not occur, or
• Evacuation and eversion of the sac behind the testis (after eversion, everted sac is
sutured with chromic catgut by continuous sutures) is done.
• If the sac is thick, in large hydrocele and chylocele,
• subtotal excision of the sac is done (as tunica vaginalis is reflected on to the cord
structures and epididymis posteriorly, total excision of the sac leads to orchidectomy
with division of cord). Often the sac is excised partially and eversion is done, which is
called as Jabouley’s operation.
• After evacuation, the sac with the testis is placed in a newly created pocket
between the fascial layers of the scrotum (Sharma and Jhawer’s
technique).
TONY 2010 MBBS 45

46. Lords plication
• Lord’s Plication is done for a Small Hydrocele.
• Done under Spinal Anaesthesia.
• Vertical Para median incision is made.
• Layers of Scrotum are divided along the line of the incision.
• Tunica vaginalis ( TV ) sac is identified.
• Tunica vaginalis Sac is opened and the Hydrocele Fluid is drained out.
• Plicating sutures are placed around the cut opened Tunica vaginalis sac.
• Achieve complete haemostasis.
• A suction drain is placed.
• Wound is closed in layers.
• Scrotal suspensory bandage is given
TONY 2010 MBBS 46

47. TONY 2010 MBBS 47

48. • Incision:
• Vertical Paramedian Procedure parallel to the median raphe of the scrotum
• Incision deepened and the Hydrocele Sac Isolated
• Hydrocele Fluid drained and Excess sac excised.
• Eversion of TV Sac ( Tunica Vaginalis sac).
• Wound is closed in layers after achieving complete hemostasis.
• Scrotal suspensory bandage applied ( Scrotal Support )
TONY 2010 MBBS 48

49. TONY 2010 MBBS 49

50. TONY 2010 MBBS 50

51. • Closure
• Drain is kept
• Suture scrotal wound
TONY 2010 MBBS 51

52. • Complication
• Injury to testis & epididymis
• Scrotal hematoma
• Recurrence
• infection
TONY 2010 MBBS 52

53. Hernia repair
TONY 2010 MBBS 53

54. Hernia repair
• Hernioplasty when herniotomy is combined with a reinforced repair
of the posterior inguinal canal with autogenous (patient’s own tissue)
or heterogenous material such as prolene mesh.
• Herniorraphy is somewhat like hernioplasty only that no autogenous
or heterogenous material is used for reinforcement.
• Herniotomy is a surgical operation where the hernia sac is removed
without any repair of the inguinal canal.
TONY 2010 MBBS 54

55. • Indications
• All hernia require Sx unless they are eldely /unfit for Sx
• Due to risk of complications of hernia
• Preparation
• Treat the predisposing cause
• c/c cough constipation BPH
• Anaesthesia
• General
• Spinal
• Local } point block field block } anaesthesia of choice
TONY 2010 MBBS 55

56. • Position
• Supine
• Cleaning & draping the area
• Incision
• ½ ‘’ above & parallel to medial to 2/3rd of inguinal ligament
• Structures cut
• skin
• 2 layers of superficial fascia
• Ligate superficial epigastric & superficialexternal pudendal
• External oblique along the direction of fibres directed towards apex of superficial
inguinal ring
• Ilioinguinal nerve is thus identified and preserved
TONY 2010 MBBS 56

57. Herniotomy
• Search for sac (pearly white in colour)
• Indirect – inside the spermatic cord anterolateral to it
• Direct– outside the cord & posteromedial to it (therefore spermatic cord is not
opened)
• Incase of indirect hernia Incise cremasteric fascia & inrenal spermatic fascia
• Expose the sac from fundus to neck separate from spermatic cord
• Divide the fundus of the sac in the inguinal canal and reduce the contents
by opening it and with fingers
• Identify the neck with
• Constriction /narrowness
• Inferior epigastric A
• Presence of extraperitoneal fat
Alone is sufficient in childrens
TONY 2010 MBBS 57

58. TONY 2010 MBBS 58

59. • Transfix and ligate the neck by needle passing technique through the
tissue to prevent slipping
• Excise the redundant sac
• Closure of the wound
TONY 2010 MBBS 59

60. Herniorraphy *(repair of posterior wall)
• Indication for In children only when there is collagen vascular
disease,severe anemia,severe malnutrition,CRF
• bassini’s repair
• The conjoined muscle of the transversus abdominis and the internal oblique
muscles is sutured to the inguinal ligament by 3-5 interrupted sutures (non
absorbable suture)
• Drawbacks
• Undue tension to relieve it tanners slide operation (transverse incision on rectus sheath)
• Recurrence due to approximation of muscle to a ligament & thick distant bites
TONY 2010 MBBS 60

61. • Modified bassini’s repair
• Conjoint tendon to inguinal ligament with continuous sutures
• shouldice repair
• 6 layers
• 1st &2nd } double breasting of fascia transversalis
• 3rd & 4th } approximate conjoint tendon to inguinal ligament in 2 layers
• 5th & 6th } double breast external oblique aponeurosis
• Spermatic cord is superficial more chance of trauma
• Modified shouldice
• Only 4 layers
• 1st &2nd } double breasting of fascia transversalis
• 3rd } approximate conjoint tendon to inguinal ligament in 1 layer
TONY 2010 MBBS 61

62. • Coopers ligament repair/mc vays repair
• inguinal and femoral canal defects
• The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
TONY 2010 MBBS 62

63. Hernioplasty
• Lichenstein tension free mesh repair
• Rives repair
• Preperitoneal mesh is kept with out suturing by incising transversalis fascia
• GPRVS/giant prosthetic reinforcement of visceral sac/stoppas repair
• By pfannensteil incision/midline vertical
• Size of mesh
• Breadth = distance B/W 2 ASIS -2cm
• Length = b/w umbilicus to pubic symphysis
• Desaradas technique
• Dynamic repair
TONY 2010 MBBS 63

64. • Closure
• External oblique is sutured with chromic catgut or silk.
• Subcutaneous fat absorbable catgut suture.
• Skin with silk.
• Post -op
• NPO fro 6-8 hours, oral fluids and soft diet later.
• Analgesics
• Antibiotics
• Scrotal support if the dissection is more(complete hernia)
• Suture removal after 7-10days.
• Post-op complications
• Haematoma
• Wound infection
• Severe peritonitis pubis
• nerve entrapment causing pain.
TONY 2010 MBBS 64

65. Varicocele repair
TONY 2010 MBBS 65

66. INDICATIONS FOR SURGERY
• A palpable varicocele.
• Symptomatic
• Pain
• Sub fertility.
• Jobs like army
TONY 2010 MBBS 66

67. • VARICOCELECTOMY-
The most common approaches are
• Palomo’s operation /high approach
• suprainguinal extraperitonial
• Classical / inguinal (groin)
• easier and safer.
• Scrotal approach-
• grade 4 varicocele
• Anaesthesia
• Spinal /LA/GA
• Position
• Supine
TONY 2010 MBBS 67

68. Classical
• Incision
• As in inguinal hernia
• Dissect out spermatic cord
• All the coverings are split open
• The vas deferens with its artery 2 veins are separated from the main
mass of varicocele
• The affected veins are ligated proximally & distally and 2 inches of
dilated veins are removed
• The ends of ligature are tied together to raise the testis up
TONY 2010 MBBS 68

69. TONY 2010 MBBS 69

70. Postoperative advice
• Avoid strenuous exercise for 2 days after surgery.
• Abx,NSAIDs
• Apply scrotal support.
TONY 2010 MBBS 70

71. Complications
• 20% chance of recurrence.
• 5% chance of hydrocele
• Damage to testicular artery.
• Infection.
• hematoma
TONY 2010 MBBS 71

72. Varicose vein repair
TONY 2010 MBBS 72

73. Varicose vein repair
• Trendelenburg operation
• Ligation & stripping
TONY 2010 MBBS 73

74. Trendelenburg operation
• Indication – Sapheno Femoral Valve incompence (trendelengurg test
+ve)
• Anesthesia :
• Spinal
• Position:
• Supine
• Incision:
• Oblique incision at the level of saphenous opening ( 4 cm below& lateral to
pubic tubercle) starting from femoral artery pulsation to 5 cm medially
TONY 2010 MBBS 74

75. • Skin flaps reflected
• Long Saphenous Vein identified in the Superficial fascia
• All the tributaries of long saphenous vein at the SFJ are ligated and divided(superficial
epigastric, superficial external pudendal,superficial circumflex iliac,medial & lateral
accessory V).
• Long saphenous vein flush ligated close to femoral vein(juxa femoral flush ligation)
• Another ligature distal to flush ligature & divide b/w 2 ligatures
• Long saphenous vein excised maximum up to upper calf to avoid injury to sural nerve
• The conventional way of removing the saphenous vein is with a Babcock stripper. This consists of a
flexible wire which is passed down the long saphenous vein. The end is identified in the upper
third of the calf and a 2-mm incision is made to retrieve the stripper. An olive about 8 mm in
diameter is attached to the upper end and the saphenous vein is removed by firm traction on the
wire in the calf.
• Haemostasis achieved and skin closed & Elastocrepe bandage applied.
• Steps 2, 3 and 4 form the components of Trendelenburg Surgery
TONY 2010 MBBS 75

76. • Complications
• Haematoma
• Recurrence (up to 20%)
• Saphenous nerve injury - loss of sensation medial thigh
TONY 2010 MBBS 76

77. Parotidectomy
TONY 2010 MBBS 77

78. • 1. Superficial parotidectomy:
• It is the removal of superficial lobe of the parotid (superficial to facial nerve.).
It is done in case of benign diseases of superficial lobe of the parotid.
• 2. Total conservative parotidectomy:
• It is done in benign diseases of parotid involving either only deep lobe or both
superficial and deep lobes. Here both lobes are removed with preservation of
facial nerve.
• 3. Radical parotidectomy:
• Both lobes of parotid are removed along with facial nerve, fat,fascia, muscles,
and lymph nodes. It is done in case of carcinoma parotid. Later facial nerve
reconstruction is done using hypoglossal or
TONY 2010 MBBS 78

79. Superficial parotidectomy
• Indication
• Recurrent parotitis
• Benign tumours
TONY 2010 MBBS 79

80. Superficial Parotidectomy
• Oral endotracheal
• Anaesthesia : GA
• Position
• Head is extended by elevating the shoulders
• Head rotated to the contralateral side
• Draping the head separately incorporating the endotracheal tube
TONY 2010 MBBS 80

81. Skin incision
Lazy S Incision
From the level of tragus of the
ear ( along the crease), winding
around the lobule towards the
mastoid and curving down
anteriorly 2 inches along the
anterior border of SCM to upper
Cervical crease.
.
TONY 2010 MBBS 81

82. Lazy s incision
TONY 2010 MBBS 82

83. Allis clamps on subcutaneous tissues provide traction of the
flaps
TONY 2010 MBBS 83

84. • The incision is carried through skin and subcutaneous tissue,
• Developing the plane between the cartilaginous external canal and
the posterior aspect of the gland
TONY 2010 MBBS 84

85. TONY 2010 MBBS 85

86. Identify cartilaginous pointer
TONY 2010 MBBS 86

87. Anatomical landmarks For identification of Facial
N Trunk
1. The cartilaginous external auditory meatus forms a pointer’ at its anterior, inferior border
indicating the direction of the nerve trunk. (Tragal Pointer)
2. Just deep to the cartilaginous pointer is a bony landmark formed by the curve of the bony
external meatus & its abutment with the mastoid process. This forms a palpable groove
(Tympanomastoid Suture) leading directly to the stylomastoid foramen.
3. The anterior, superior aspect of the posterior belly of the digastric
4. Styloid process itself can be palpated superficial to the stylomastoid foramen & just superior
to it. Nerve is always lateral to this plane & passes obliquely across the styloid process.
5. Retrograde Dissection
TONY 2010 MBBS 87

88. The mastoid process palpated to identify the
origin of the sternocleidomastoid
The sternomastoid muscle is identified and
its anterior border exposed as the tail of the
gland is dissected and reflected away from
the muscle
TONY 2010 MBBS 88

89. Identify anterior border of posterior belly of
digastric
Continues to dissect in this plane, incising
attachments to the mastoid, until the
posterior belly of the digastric muscle is
visualized below the digastric groove
TONY 2010 MBBS 89

90. • When the volar aspect of the fifth finger is placed deeply on the
junction of cartilaginous and bony external auditory canal and
wedged against the bone cephalad, the main trunk will be found
below the inferior border of the finger, a few millimeters above the
exposed superior border of the posterior belly of the digastric muscle
as it enters its groove in the mastoid bone
TONY 2010 MBBS 90

91. TONY 2010 MBBS 91

92. Identify facial nerve trunk
TONY 2010 MBBS 92

93. • Once the facial nerve trunk has been identified the superficial lobe
exteriorised by opening up the plane in which the branches of the
facial nerve run between the two lobes by blunt dissection
• Small hemostat in the plane superficial to N, elevating the hemostat
laterally, gently spreading the tips, and then incising the tissue
between the tips with direct visualization of the N
• Good traction on the reflected parotid
• Clamp is used to elevate and incise the overlying tissue in layers
TONY 2010 MBBS 93

94. After the lateral portion of the gland has been
removed, all nerve branches should be exposed.
If a clean dissection has been performed, at least a portion of
the masseter muscle should be in view
TONY 2010 MBBS 94

95. •The Stensen duct is
transected and ligated
anteriorly
TONY 2010 MBBS 95

96. Suture & keep drain
drain
TONY 2010 MBBS 96

97. Conservative parotidectomy
TONY 2010 MBBS 97

98. TONY 2010 MBBS 98

99. TONY 2010 MBBS 99

100. Complications
Intra-operative complications
• Transection of facial nerve
• Rupture of capsule
• Haemorrhage
TONY 2010 MBBS 100

101. Post Operative Complications
Early Late
• Facial N Paralysis
• Hemorrhage
• Hematoma
• Infection
• Skin Flap Necrosis
• Cosmetic Deformity
• Trismus
• Parotid Fistula
• Hypoaesthsia
• Soft Tissue Defect
• Hypertrophic Scar
• Frey’s Syndrome
• Crocodile tear
syndromr
TONY 2010 MBBS 101

102. Intra Op Transection OF Facial N
• Immediate nerve repair
• Segments fully mobilized
• Brought together without tension
• Two ends should be sutured together
• With an 8-0 nylon suture
• As an alternative to sutures, fibrin tissue adhesive can be used.
• If the nerve length is inadequate, a nerve graft of the greater
auricular
TONY 2010 MBBS 102

103. Mastectomy
TONY 2010 MBBS 103

104. TONY 2010 MBBS 104

105. Operative procedures-Mastectomy
1. Simple mastectomy.
2. Modified radical mastectomy.
3. Breast conserving surgery.
TONY 2010 MBBS 105

106. Total or simple mastectomy:
• Removal of the entire breast tissue,
• No dissection of lymph nodes or removal of muscle.
• Sometimes adjacent lymph nodes are removed along
with the breast tissue.
TONY 2010 MBBS 106

107. Which procedure is best ?
• Loco-Regional therapy include:
a. Surgery
b. Radiotherapy
• Systemic therapy:
a. Chemotherapy
b. Hormonal therapy
c. Monoclonal antibodies.
However surgery is important to get rid of gross cancer
TONY 2010 MBBS 107

108. Pre-operative management
• Triple assessment.
• Metastatic workup.
• Routine blood investigations.
• Pre-anesthetic evaluation.
• Control of medical conditions like diabetes and hypertension.
• Counseling and written informed consent.
• Parts preparation- neck to mid thigh including pelvic region, axilla
and arm.
TONY 2010 MBBS 108

109. Operative procedure
• Anesthesia
• General anesthesia.
• Position
• The patient is placed in supine position with the arm
abducted < 90 degree.
• Sandbag or folded sheet is placed under the thorax and
shoulder of affected side.
TONY 2010 MBBS 109

110. Operative procedures- Simple Mastectomy
• Indications:
• Stage I and stage IIa carcinoma
• Large cancers that persist after adjuvant therapy
• Multifocal or multicentric CIS.
• Incision:
• Horizontal elliptical incision is marked so as to include the entire
areolar complex.
• Should be 1-2cm away from the tumor margins.
• Skin sparing incision- if breast reconstruction is planned
• Two skin edges should be of equivalent length
TONY 2010 MBBS 110

111. TONY 2010 MBBS 111

112. TONY 2010 MBBS 112

113. TONY 2010 MBBS 113

114. Simple Mastectomy-procedure
• Skin incision is deepened with electro-
cautery.
• A plane between breast fat and the
subcutaneous fat, seen as white fibrous
plane.
• Dissection is carried in this plane and
flaps are raised inferiorly and superiorly.
• Ideally thickness of the flap should be 7-
10mm.
TONY 2010 MBBS 114

115. Simple Mastectomy-procedure
• Extent of dissection:
• Superiorly till clavicle,
• Laterally till P.major lateral border
• Medially to the sternal border, and
• Inferiorly till infra-mammary fold
• Breast tissue along with the pectoral fascia
(controversial) is dissected from the P.major.
TONY 2010 MBBS 115

116. Simple Mastectomy-procedure
• Usually started superiorly and the proceeded clock-wise ending
in the axillary region.
• Care must be taken to ligate perforating branches of lateral
thoracic and anterior intercostal vessels.
• Lateral branches of the medial pectoral neurovascular bundle is
carefully dissected while removing axillary tail.
• Wound irrigated with sterile water to crenate (shrivel or shrink)
cancerous cells.
• Subcutaneous tissue is closed using 00 absorbable interrupted
sutures.
• Skin closed using 00 non-absorbable mattress sutures or using
staples.
TONY 2010 MBBS 116

117. Modified Radical Mastectomy (MRM):
• Removal of breast tissue and axillary lymph nodes.
• No removal of pectoral muscle.
• 3 modifications:
a. Patey’s
b. Scanlon’s.
c. Auchincloss.
TONY 2010 MBBS 117

118. Modified radical Mastectomy-procedure
1. Patey’s procedure:
• The P.minor is removed for better visualization and easy
dissection of level III lymph nodes.
2. Scanlon’s procedure:
• P.minor is retracted to expose level III nodes and dissected out.
3. Auchincloss procedure:
• Level I and II lymph nodes are cleared, level III nodes are left
behind.
TONY 2010 MBBS 118

119. Operative procedures- Modified radical
Mastectomy
• Indications:
• Early breast cancer (most commonly done)
• LABC
• Residual large cancers that persist after adjuvant therapy
• Multifocal or multicentric disease.
• Incision:
• Oblique elliptical incision angled towards axilla.
• Should include the entire areolar complex and previous scars, if present.
• Should be 1-2cm away from the tumor margins.
• Two skin edges should be of equivalent length
TONY 2010 MBBS 119

120. Modified radical Mastectomy-procedure
• Procedure till approaching axilla is
same as simple mastectomy.
• Extent of dissection:
• Superiorly till clavicle,
• Laterally till anterior margin of
latissimus dorsi.
• Medially to the sternal border, and
• Inferiorly till the costal margin near the
insertion of the rectus sheath.
TONY 2010 MBBS 120

121. Modified radical Mastectomy-procedure
• The specimen is retracted upwards and laterally to expose
P.minor.
• The dissection is continued to axillary lymph node
clearance.
• Care must be taken not to injure medial pectoral nerve
and vessels.
• The axillary investing fascia is incised to expose the
axillary group of lymph nodes.
TONY 2010 MBBS 121

122. Modified radical Mastectomy-procedure
• The inter-pectoral (Rotter) group of lymph nodes are removed.
• Then dissection can be done either from medial to lateral or vise-
versa.
• The loose lateral areolar tissue in axillary space is dissected to
expose the axillary vein.
• The investing layer of axillary vessels is cut, the tributaries are
transfixed and cut.
• Dissection is carried out laterally including lateral grp (level I) of
lymph nodes.
TONY 2010 MBBS 122

123. Modified radical Mastectomy-procedure
• Thoracodorsal neurovascular bundle lies over the lat.dorsi, with
nerve more laterally placed, subscapular (level I) nodes are removed.
• The level II lymph nodes between superior trunk of
intercostobranchial bundle and axillary vein are removed.
• The central grp of lymph nodes are removed carefully separating
from axillary vein and its tributaries.
• While dissecting medially, long thoracic nerve is encountered, which
lies anterior to the subscapular muscle. The dissection carried out
anterior and medial to long thoracic nerve and the specimen
delivered.
TONY 2010 MBBS 123

124. Modified radical Mastectomy-procedure
• Care must be taken while dissecting in axillary area to
preserve,
• Medial and lateral pectoral nerve.
• Long thoracic vessels and nerve
• Nerve to latissimus dorsi.
• Axillary vein.
• Wound irrigated with sterile water to shrink/crenate
cancerous cells.
• 2 drains, 1 below and other above P.major are secured.
• Subcutaneous tissue is closed using 00 absorbable
interrupted sutures.
• Skin closed using 00 non-absorbable mattress sutures or
using staples.
TONY 2010 MBBS 124

125. TONY 2010 MBBS 125

126. Post-operative care
• Wound examined on post-op day 3.
• Drain can be removed when it is < 30ml.
• Any collection is to be aspirated under aseptic precautions.
• Staples can be removed after 10days.
• Arm movements started in the 1st week..
• Active shoulder and upper limb exercises are started from 2
weeks
TONY 2010 MBBS 126

127. Types of mastectomy
3. Halsted’s Radical Mastectomy:
• Most extensive type.
• Breast tissue, axillary lymph nodes and pectoral muscles are removed.
• Disadvantages:
• Bad scars and unacceptable deformity.
• Reduced range of mobility of shoulder
TONY 2010 MBBS 127

128. Types of mastectomy
4. Subcutaneous mastectomy:
• Simple mastectomy sparing nipple.
• Rarely done, as a large amount of
breast tissue is left in situ.
5. Skin sparing mastectomy:
– Total/simple mastectomy or
modified radical mastectomy
with preservation of as much
as breast skin as possible
needed for breast
reconstruction.
– Local recurrence is
acceptable, 0-3%.
TONY 2010 MBBS 128

129. Types of mastectomy
6. Breast conserving surgery:
• Wide local excision/Lumpectomy
• Quadrantectomy.
TONY 2010 MBBS 129

130. Breast conserving surgery
• Indications:
• Stage 0 (CIS), Stage I,
Stage IIa breast
carcinoma.
• Single lesion.
• Clinically downstaged
LABC (controversial)
• Method:
• Wide local
excision/Lumpectomy or
Quadrantectomy +
axillary lymph node
clearance +
radiotherapy.
TONY 2010 MBBS 130

131. Types of mastectomy
7. Extended radical
mastectomy:
• Radical mastectomy +
enbloc resection of
internal mammary lymph
nodes + supraclavicular
lymph nodes.
• Obsolete.
8. Toilet mastectomy:
• Done in fungating or
ulcerative growths.
• Palliative simple
mastectomy.
TONY 2010 MBBS 131

132. Which procedure is suitable for the given patient ?
• Age
• Size of the tumor
• Axillary lymph node status.
• Stage of the malignancy
• Biologic aggressiveness of the
tumor
• Receptor status of the tumor.
• Multicentricity or multifocality
• Menstrual status.
• Size of the breast
• Availability of
radiotherapy.
• Patients choice.
• Prophylactic/therapeutic/
palliative.
TONY 2010 MBBS 132

133. Which procedure is best ?
• When the tumor size is ≥ 1cm, becomes systemic.
• No single method is considered better in terms of
disease free survival or mortality.
• Suitable local therapy + systemic therapy is the most
appropriate approach.
TONY 2010 MBBS 133

134. Breast conserving surgery
• Advantages:
• Maintenance of appearance
and function of breast.
• Disease free interval is same as
MRM.
• Better quality of life and
psychological advantage.
• Contraindications:
• Multicentric tumor.
• Positive margins after excision.
• Size > 4cm (relative).
• Advanced stages.
• No assess to radiation/ poor
patient compliance.
• C/I for radiation: SLE/ Rheumatoid
arthritis/ Scleroderma/ pregnancy/
prior chest radiation.
TONY 2010 MBBS 134

135. Breast conserving surgery-Procedure
• Incision-circular/ radial/ subareolar incision near to the tumor,
about 3-4cm.
• Excision of the carcinoma tissue with a margin of atlaeast 1cm
of normal breast tissue to get a 2-mm cancer-free margin.
• If tumor is situated superficially then excision of that part of skin.
• If tumor is deep then tumor is excised till pectoralis major.
• Depending on post-surgical defect
• Primary closure or
• Reshaping of breast tissue is done.TONY 2010 MBBS 135

136. Breast conserving surgery-Lumpectomy
• After skin incision, subcutaneous tissue is deepened using electric
cautery.
• While dissecting the breast tissue, better to use scalpel.
• Care must be taken while dissecting to palpate the tumor, so that
entire lesion is excised. Specimen radiography can be done to check
for clear margins.
• Hemoclips are applied along the margins of the cavity.
• Wound closed in 2 layers:
• Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.
• Skin with subcuticular 3-0 absorbable sutures.
TONY 2010 MBBS 136

137. Breast conserving surgery-Procedure
Quadrantectomy:
• Usually done for lesion in the upper outer and inner lower
quadrants.
• Radial incision is taken.
• Entire breast tissue in that quadrant is excised till pectoral fascia.
• Wound closed in multiple layers:
• Breast tissue with interrupted 3-0 absorbable suture.
• Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.
• Skin with subcuticular 3-0 absorbable suture.
TONY 2010 MBBS 137

138. Breast conserving surgery
• Quadrantectomy v/s Lumpectomy.
• Lumpectomy has more local recurrence risk.
• Lumpectomy has better cosmetic outcome.
TONY 2010 MBBS 138

139. Breast conserving surgery
• After BCS, radiotherapy is essential, otherwise the
local recurrence rate is unacceptably high
• Without radiotherapy, the local recurrence can be as
high as 40%
TONY 2010 MBBS 139

140. Neck dissection
TONY 2010 MBBS 140

141. Neck dissection
• Medina classification (1989)
• • Radical neck dissection
• • Extended radical neck dissection
• • Modified radical neck dissection
• Type I (XI preserved)
• Type II (XI, IJV preserved)
• Type III (XI, IJV, and SCM preserved)(Known as Functional neck dissection (Bocca))
• • Selective neck dissection
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection
TONY 2010 MBBS 141

142. Radical neck Dissection:
Removes
• Removing all lymphatic tissues in
regions I - V
• Spinal Acessory Nerve
• Internal Jugular vein
• Sternocleidomastoid muscle
• Submandibular Salivary gland
• Tail of parotid
• Omohyoid muscle
Preserves
• Posterior auricular
• Suboccipital
• Retropharyngeal
• Periparotid
• Perifacial
• Paratracheal nodes
TONY 2010 MBBS 142

143. Indications
• Radical Neck Dissection
1. Multiple clinically obvious cervical lymph node metastasis particularly of
posterior triangle and closely related to SAN
2. Large metastatic tumor mass or multiple matted in upper part of the neck
• Tumor should not be dissected to preserve Structures

144. Contraindications
• 1. untreatable primary lesion (fixed)
• 2. Involvement of internal / common carotid artery
• 3. Presence of distant metastasis.
• 4. Poor anaesthetic risk patient.
TONY 2010 MBBS 144

145. Modified radical neck dissection:
• Excision of all lymph nodes removed with RND (Nodal groups I-V)
• with preservation of one or more non-lymphatic structures, SAN, SCM and/or
IJV
• Subtype I: Preserve SAN
• Subtype II: Preserve SAN & IJV
• Subtype III: preserve SAN, IJV and SCM
• Known as Functional neck dissection (Bocca)
TONY 2010 MBBS 145

146. Type l MRND
TONY 2010 MBBS 146
(XI preserved)
Indications
– Clinically obvious lymph node metastases
– SAN not involved by tumor
–Intraoperative decision

147. Type ll MRND
TONY 2010 MBBS 147
Preserve SAN
&
IJV
• Indications
– Rarely planned
– Intraoperative tumor found adherent to the SCM, but not IJV
& SAN

148. Type lll MRND/ Functional neck dissection
TONY 2010 MBBS 148
preserve SAN, IJV and SCM
• Neck dissection of choice for N0 neck For treatment of N0 neck nodes
Indicated for N1 mobile nodes and not greater than 2.5 – 3.0
cm
Contra-indicated in the presence of node fixation
Result is difficult to interpret because of the use of radiation
therap

149. Extended Neck Dissection
• Definition
• – Any previous dissection which includes removal of one or more
additional lymph node groups and/or non-lymphatic structures.
• – Usually performed with N+ necks in MRND or RND when
metastases invade structures usually preserved
TONY 2010 MBBS 149

150. Selective Neck dissection:
• Also known as an elective neck dissection
• Need for post-op RT
• Any type of cervical lymphadenectomy with preservation of one or more
lymph node groups
• Four subtype:
• Supraomohyoid neck dissection
• Posterolateral neck dissection
• Lateral neck dissection
• Anterior neck dissection
TONY 2010 MBBS 150

151. Indications
• Selective/elective neck dissection:
• For treatment of N0 neck nodes
• For N+ nodes when combined with radiotherapy
• Adjuvant radiotherapy for patient with 2 – 4 positive
nodes or extra-capsular spread
• Upgrade intra-operatively following positive frozen section

152. Supraomohyoid neck dissection
• Most commonly performed SND
• Definition
• – En bloc removal of cervical lymph node groups I-III
– Posterior limit is the cervical plexus and posterior border of the SCM
– Inferior limit is the omohyoid muscle overlying the IJV
TONY 2010 MBBS 152

153. Supraomohyoid neck dissection
TONY 2010 MBBS 153
Indications
Oral cavity carcinoma with N0 neck
• Boundaries – Vermillion border of lips to junction of hard and
soft palate, circumvallate papillae
• Subsites - Lips, buccal mucosa, upper and lower alveolar ridges,
retromolar trigone, hard palate, and anterior 2/3s of the tongue and
FOM

154. Lateral Type
• En bloc removal of the jugular lymph nodes including Levels II-IV.
• Indications
N0 Neck in carcinomas of
• Oropharynx
• Hypopharynx
• Supraglottis
• Glottic Larynx

155. Posterolateral type
En bloc excision of lymph bearing tissues in Levels II-IV and additional
node groups – suboccipital and postauricular.
• Indications
• – Cutaneous malignancies
• • Melanoma
• • Squamous cell carcinoma
• • Merkel cell carcinoma
• – Soft tissue sarcomas of the scalp and neck
TONY 2010 MBBS 155

156. Anterior neck dissection
• En bloc removal of lymph structures in Level VI
• • Perithyroidal nodes
• • Pretracheal nodes
• • Precricoid nodes (Delphian)
• • Paratracheal nodes along recurrent nerves
• Limits of the dissection are the hyoid bone, suprasternal notch and carotid
sheaths
• Indications
• – Selected cases of thyroid carcinoma
• – Parathyroid carcinoma
• – Subglottic carcinoma
• – Laryngeal carcinoma with subglottic extension
• CA of the cervical esophagus
TONY 2010 MBBS 156

157. Y Incision
3 point
intersectionflap
necrosis

158. McFee Incision

159. H Incision

160. J Incision

163. COMPLICATIONS
•Air embolus
•Pneumothorax
•Chyle leak & Chylus fistula
•Wry Neck (Torticollis Coli)
•Shoulder dysfunction
•Cerebral oedema

164. Incision and drainage of abscess
TONY 2010 MBBS 164

165. • Indications
• 1. Abscess on the skin which is palpable
• Contraindications
• 1.Extremely large abscesses which require extensive incision, debridement, or
irrigation (best done in OR)
• 2. Deep abscesses in very sensitive areas (supralevator, ischiorectal,
perirectal) which require a general anesthetic to obtain proper exposure
• 3. Palmar space abscesses, or abscesses in the deep plantar spaces
• 4. Abscesses in the nasolabial folds (may drain to sphenoid sinus, causing a
septic phlebitis)
TONY 2010 MBBS 165

166. • Preprocedure education
• 1. Obtain informed consent
• 2. Inform the patient of potential severe complications and their treatment
• 3. Explain the steps of the procedure, including the not insignificant pain associated
with anesthetic infiltration
• 4. Explain necessity for follow-up, including packing change or removal
•
• Procedure
• 1. Use universal precautions
• 2. Cleanse site over abscess with skin prep
• 3. Drape to create a sterile field
• 4. Infiltrate local anesthetic, allow 2-3 minutes for anesthetic to take effect
• 5. Incise widely over abscess cutting through the skin into the abscess cavity. Follow
skin fold lines whenever able while making the incision
TONY 2010 MBBS 166

167. • 6.Allow the pus to drain, using the gauzes to soak up drainage and
blood. Use culture swab to take culture of abscess contents, swabbing
inside the abscess cavity
• 7.Use the hemostat to gently explore the abscess cavity to break up
any loculations within the abscess
• 8. Using the packing strip, pack the abscess cavity
• 9. Place gauze dressing over wound, and tape in place
TONY 2010 MBBS 167

168. TONY 2010 MBBS 168

169. TONY 2010 MBBS 169

170. Excision of lipoma
TONY 2010 MBBS 170

171. • Indication
• Large size (cosmesis/patients wish)
• Recent rapid increase in size (sarcomatous change)
• Symptomatic naevo/neurolipomas
• causing pressure symptoms based on site.
TONY 2010 MBBS 171

172. • Surgical procedures
• Incision: A linear incision over the summit of the swelling is placed and flaps raised
on both sides of the incision.
• Layers opened: skin and some part of the subcutaneous tissue till the capsule of the
swelling is encountered.
• Dissection : using an artery forceps or a moquito forceps( if a small swelling) , a plane
is created between the raised flaps and the capsule of the swelling.Pressure is given
at the base of the swelling to deliver out of lipoma.A small vessel may be
encountered as the base is being dissected that should be identified and cauterised
or ligated.The specimen should be sent for hisptopathological evaluation.
• Closure
• The cavity left after the excision can be closed by few interrupted vicryl sutures to
close the subcutaneous layer. The excess skin is removed. The skin is closed with 2.0
ethilon vertical mattress suture. Sometimes a drain may have to be kept to drain the
cavity.Remove suture after 7-10days.
TONY 2010 MBBS 172

173. Excision of sebaceous cyst
TONY 2010 MBBS 173

174. • Indication : Infection , cosmesis
• Surgical procedure:
• Elliptical incision around the summit of the swelling encircling the punctum.
• Layers opened:
• Incision should be superficial. Care should be taken not to cut open the cyst wall.
• The principle is to completely excise the cyst with its wall and the overlying punctum and a bit of
the surrounding skin around the punctum.
• Dissection
• A plane is created between the skin and the cyst, carefully, preventing opening of the cyst wall.
• An Allis forceps may be applied to the punctum and the elliptical skin to get a traction. Flaps need
to be raised gradually on either sides of the incision and then deliver the cyst in toto.(huh?)
• If the cyst wall opens up, the sebum is removed completely and an effort to remove all the cyst
wall in piece meal is made.
• Closure: Single layer closure of the skin. suture removed after 7-10 days.
TONY 2010 MBBS 174

175. Thanks to
• Our Teachers
• Noufal T B
• Wajidha P K
• Tintu Rose Thomas
• Swathikrishna Babu
• Vivek Krishna M S
• Tariq Navas
• Thomas John
• Thouseef Muhammed K M
• Umbing Mudang
TONY 2010 MBBS 175