Operations

Hepatobiliary Unit Prepared By / Doctor Neotin

…

1.SPLENECTOMY

1) INDICATION::

a- Hypersplenism.

b- Trauma.

c- Heamolytic aneamia.

d- ITP.

e- Hodgkin.

f- part of other operation: (e.g. gastrectomy, portal decompression).

2) STEPS:

a- General anesthesia in supine position + skin preparation.

b- Incision: midline (in trauma), or left subcostal ( kocher), or upper left

paramedian(skin, s.c.,

anterior abdominal wall {mention}).

c- Division of adhesions and suction of blood if present.

d- By the left hand draw the spleen medially to divide lino-renal

ligament(posterior layer), and

deliver spleen into the wound

e- Division of gastro-splenic ligament and anterior layer of lino-renal to

expose splenic vessels

f- division of artery then squeeze(auto-transfusion) then the vein is divided.

g- Divide peritoneal adhesions to stomach and colon.

h- complete exploration

i- Absolute hemostasis.

j- Closure with drain.

3) PRE-OPERATIVE PREPARATION:

a- Correct the general condition.

b- Preoperative investigation.

c- preoperative medication: Morphine + Hyoscin.

4) OPERATIVE COMPLICATIONS:

a- SHIP :

Shock. Hemorrhage.(primary). Injury of important structures : colon, pancrease,

stomach. pulmonary complications.

b- Complications of anesthesia :

5) POST-OPERATIVE COMPLICATIONS :

a- General :

Reactionary and secondary hemorrhage. Infection. Respiratory obstruction. Wound complications: (Keloid and hypertrophic scar ----

> disfigurement). b- Specific :

Hematemesis (PU and varicis). Fudal ischemia. Gastric perforation. Acute gastric dilatation. Acute pancreatitis, and pancreatic fistula. Burst abdomen. Post splenectomy sepsis. Thrombocytosis.

6) POST-OPERATIVE CARE :

a- General for any operation :

observation of vital and clinical signs. Antibiotics, analgesics, and dressings. Drain : 5th day. Stitches : 7th day.

b- Specific :

Pneumo-coccal vaccine. Penicilline and aspirin.

2.OPEN CHOLECYCTECTOMY

1) INDICATION::

a- Chronic calcular cholecyctitis.

b- Chronic non-calcular with medical failure.

c- Acute cholecyctitis.

d- Empyma and mucocele of GB.

e- Tumor and trauma.

2) STEPS:

a- General anesthesia in supine position with elevation of the right

hypochondrium + skin preparation.

b- Incision: Kocher incision or right upper paramedian.

c- Explore the abdomen.

d- Introduce the hand between the liver and diaphragm to displace the liver

below the costal margin.

e- Then retract the liver upwards by Daeuver's retractor.

f- Retract stomach and duodenum.

g- Retract GB laterally.

h- Incise peritoneum.

i- Dissect the triangle of Calot.

j- Ligate and divide cystic artery and duct.

k- Intraoperative assessment : (choledecoscope, cholangiography).---> to

avoid missed stone.

l- Histopathology.

m- Absolute hemostasis.

n- Closure with drain.

3) PRE-OPERATIVE PREPARATION:

a- Correct the general condition.

b- Preoperative investigation : U/S.

c- preoperative medication: Morphine + Hyoscin + liver support + vit.K +

cephalosporine + fluids.

4) OPERATIVE COMPLICATIONS:

a- SHIP :

* Shock. * Hemorrhage.(primary). * Injury of important structures : ............................ * pulmonary complications.

b- Complications of anesthesia :

c- Specific : Difficult closure of deoudenal stump.

5) POST-OPERATIVE COMPLICATIONS :

a- General :

* Reactionary and secondary hemorrhage. * Infection. * Respiratory obstruction. * Wound complications: (Keloid and hypertrophic scar ----

> disfigurement). b- Specific :

* Missed stone. * Post-cholecyctectomy syndrome. * Jaundice. * Incisional hernia.

6) POST-OPERATIVE CARE :

a- General for any operation :

* observation of vital and clinical signs. * Antibiotics, analgesics, and dressings. * Drain : 5th day. * Stitches : 10th day.

b- Specific :

* Gastric suction for 48h. * Care of T-tube (mention). * Never to remove T-tube before 2 days.

13/12/2012