Excision of swellings

A.LIPOMA

Indication

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

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.

B.SEBACEOUS CYST

Indication : Infection , cosmesis

Surgical procedure: 

• Elliptical incision around the summit of the swelling encircling the punctum.
• Layers opened:

1. Incision should be superficial. Care should be taken not to cut open the cyst wall.
2. 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 

1. A plane is created between the skin and the cyst, carefully, preventing opening of the cyst wall.
2. 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?)
3. 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.

Appendicectomy

Indications: Acute appendicitis, recurrent appendicitis

Procedure:

Incision

• McBurney's grid incision is the most popular incision. it is right angles to the spino-umbilical line placed at Mcburney's point.It is about 6-8cm in length.
• Lanz incision are cosmetically better than McBurney's.
• Right paramedian incision is made when diagnosis is in doubt as a part of exploratomy laparotomy.

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.

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.Perfect haemostasis is obtained.

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 cavity.

Tracheostomy

Definition : An opening made in the trachea is called tracheostomy.

Indication:

• Emergency: choking, stridor
• Elective: Coma , tetanus, barbiturate,head injuries, pulmonary insufficiency

Contraindications:

• Anaplastic carcinomathyroid patients presenting with stridor due to infiltration of growth into trachea. 

Anaesthesia: LA

Procedure:

• Incision: Tranverse curved incision 3-4cm at the level of 2nd tracheal ring. 
• 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).
• 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.

Post op Rx

• Suction of tracheostomy tube
• Regular dressing
• Humidification of air
• Check for air entry

Post op complication

• wound infection
• Air leakage
• Improper air entry
• cricoid stenosis

Herniotomy Step By step

  

-indicated in children with inguinal hernia & before herniorrhaphy in adults

-Procedure:

1-ligate & divide the 3 superficial veins
2-divide the external oblique aponeurosis in the direction of its fibers
3-reflect the external oblique aponeurosis &identify the ilioinguinal nerve & reflect it over the aponeurosis
4-separate the cord from posterior wall of the canal
5-divide the creamasteric muscle & internal spermatic fascia
6-dissect the hernial sac up to its neck
7-open the fundus of the sac
8-reduce the contents
9-transfix the sac at the deep ring
10-excise the redundant sac


There are different approaches to surgical repairs to hernia which may include the following:

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.

Read more: Discussion on Hernia Repair, Herniorraphy | Res Ipsa Loquitur - OR Nurse 

*updated

Herniorrhaphy procedure: Bassini's 

Definition: It means herniotomy and approximation of conjoined tendon to inguinal ligament to strengthen the posterior wall of the inguinal canal.

Indication: Indirect  or direct hernia with good muscle tone.

Procedure

Incision: 6-8cm incision is made parallel to the inguinal ligament at the level of deep ring in the medial two thirds of the inguinal ligament. 

Layers opened: 

• Skin
• Two layers of superficial fascia
• External oblique is incised in the line of direction fibres till external ring is open.
• Thin cremasteric box is opened.
• Identification of the sac

1. - glistening white colour,
2. Isolate the cord from the sac by blunt and sharp dissection.The cord is held separately by using cord holding forceps.
3. The sac is mobilise upto the deep ring. Mobilisation is complete when inferior epigastric artery pulsations and extraperitoneal pad of fat are seen.
4. The sac is opened and contents are examined.
5. The contents are reduced.
6. Twist the sac to avoid injury to the contents.
7. Transfixation ligature is applied as high as possible at the neck of sac and it is tightened.
8.  Excision of the sac: After excision , see the excised sac and see whether omentum or intestine have been injured.Up to this stage , it is called as HERNIOTOMY.

Repair

• Conjoined tendon above is approximated to the inguinal ligament below by using nonabsorbable suture such as Nylon, Silk  or Sutupack.
• Nonabsorbable suture is used so that its strength remaines for a long time. This repair is called BASSINI'S HERNIORRHAPHY.

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. 

Source: Shenoy Nileshwar Manipal Manual surgery.