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Answer the following questions
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Here is a brief explanation of all 18 OT procedures listed:
OT PROCEDURES - Brief Explanations
1) Jaboulay's Operation
A surgical procedure for chronic epididymo-orchitis or hydrocele where the tunica vaginalis is everted and sutured behind the testis (rather than excised). It drains the hydrocele sac and prevents reaccumulation. Also used in some cases of testicular torsion workup.
2) Open Inguinal Hernioplasty
Surgical repair of an inguinal hernia through an open incision in the groin. The hernial sac is reduced and the posterior wall of the inguinal canal is reinforced using a mesh (Lichtenstein tension-free repair is most common) or suture-based techniques (Bassini, Shouldice).
3) LAP TAPP Inguinal Hernia Repair
Transabdominal Preperitoneal (TAPP) repair is a laparoscopic approach to inguinal hernia. The surgeon enters the peritoneal cavity, dissects the preperitoneal space, and places a mesh to cover the hernia defect from inside, then closes the peritoneum over it.
4) Open Appendicectomy
Surgical removal of the appendix through an open incision (classically a Lanz or Gridiron incision in the right iliac fossa). Performed for acute appendicitis. The mesoappendix is ligated, the appendix base tied off and excised.
5) Laparoscopic Appendicectomy
Removal of the appendix using 3 laparoscopic ports. The mesoappendix is divided using a stapler or electrocautery, and the appendix base is secured with endoloops or a stapler before removal. Benefits include less pain, faster recovery, and lower wound infection rates.
6) Laparoscopic Cholecystectomy
Removal of the gallbladder laparoscopically - the gold standard for symptomatic gallstones (cholelithiasis) and acute cholecystitis. Uses 4 ports. The cystic duct and cystic artery are clipped and divided, and the gallbladder is dissected off the liver bed and removed.
7) Fibroadenoma Excision
Surgical removal of a fibroadenoma - a benign breast lump composed of fibrous and glandular tissue. Performed under local or general anaesthesia through a small incision over the lump. Indicated when the lump is large (>3 cm), growing, causing anxiety, or at patient request.
8) Circumcision
Surgical removal of the foreskin (prepuce) of the penis. Indications include phimosis, paraphimosis, recurrent balanitis, and religious/cultural reasons. Techniques include the sleeve resection, dorsal slit, or Plastibell method in neonates.
9) Modified Radical Mastectomy (MRM)
Removal of the entire breast along with axillary lymph nodes (levels I, II) but preserving the pectoralis major muscle (unlike the Halsted radical mastectomy). Performed for breast cancer. The pectoralis minor may or may not be removed.
10) Feeding Jejunostomy
Surgical creation of an opening into the jejunum through the abdominal wall to allow enteral feeding, bypassing the stomach and duodenum. Performed in patients with oesophageal/gastric pathology, post-oesophagectomy, or prolonged inability to swallow.
11) Thyroidectomy
Surgical removal of part or all of the thyroid gland. Types include:
- Hemithyroidectomy - one lobe
- Total thyroidectomy - entire gland
- Subtotal - most of the gland
Indicated for thyroid cancer, large goitre, Graves' disease, or compressive symptoms. Key risks: recurrent laryngeal nerve injury and hypoparathyroidism.
12) Hemicolectomy
Removal of half of the colon:
- Right hemicolectomy - ascending colon + hepatic flexure (for right-sided colon cancer or Crohn's)
- Left hemicolectomy - descending colon + splenic flexure (for left-sided colon pathology)
Followed by anastomosis to restore bowel continuity.
13) Gastrectomy
Surgical removal of part or all of the stomach:
- Partial (subtotal) gastrectomy - for gastric cancer or refractory peptic ulcer
- Total gastrectomy - entire stomach removed, oesophagus anastomosed to jejunum (Roux-en-Y)
Indicated mainly for gastric carcinoma.
14) Abdomino-Perineal Resection (APR)
A major colorectal surgery for low rectal cancer where the sigmoid colon, rectum, and anus are all removed. A permanent colostomy is created. Performed via both abdominal and perineal approaches simultaneously (hence the name). The anal sphincters cannot be preserved in this procedure.
15) Whipple's Procedure (Pancreaticoduodenectomy)
A complex operation for cancer of the head of the pancreas, ampullary tumours, or bile duct cancer. Involves removal of:
- Head of pancreas
- Duodenum
- Distal common bile duct
- Gallbladder
- Distal stomach (classic) or pylorus preserved (PPPD)
Followed by reconstruction with pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy.
16) Lateral Pancreaticojejunostomy (Puestow Procedure)
A drainage procedure for chronic pancreatitis with a dilated pancreatic duct (>7 mm). The pancreatic duct is opened longitudinally and anastomosed side-to-side to a loop of jejunum (Roux-en-Y), allowing pancreatic juice to drain freely and relieving pain.
17) Tracheostomy
Surgical creation of an opening in the anterior wall of the trachea and insertion of a tracheostomy tube. Performed for:
- Prolonged ventilation (ICU patients)
- Upper airway obstruction
- Bilateral vocal cord paralysis
- Head and neck cancers
Can be surgical (open) or percutaneous dilational (bedside technique).
18) Open Cystogastrostomy
A surgical drainage procedure for pancreatic pseudocyst - the pseudocyst (which lies adjacent to the posterior wall of the stomach) is opened into the stomach, creating a permanent internal drainage channel. The pseudocyst fluid drains into the stomach and is excreted naturally.
Summary Table:
| # | Procedure | Organ/System |
|---|---|---|
| 1 | Jaboulay's | Testis/Hydrocele |
| 2 | Open Hernioplasty | Inguinal canal |
| 3 | LAP TAPP | Inguinal canal |
| 4 | Open Appendicectomy | Appendix |
| 5 | Lap Appendicectomy | Appendix |
| 6 | Lap Cholecystectomy | Gallbladder |
| 7 | Fibroadenoma Excision | Breast |
| 8 | Circumcision | Penis/Prepuce |
| 9 | MRM | Breast/Axilla |
| 10 | Feeding Jejunostomy | Small bowel |
| 11 | Thyroidectomy | Thyroid |
| 12 | Hemicolectomy | Colon |
| 13 | Gastrectomy | Stomach |
| 14 | APR | Rectum/Anus |
| 15 | Whipple's | Pancreas/Duodenum |
| 16 | Lateral PJ | Pancreas |
| 17 | Tracheostomy | Trachea |
| 18 | Open Cystogastrostomy | Pancreatic pseudocyst |
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1000129373.jpg
Answer the following questions
Asking for Preferences
Here is a detailed breakdown of all 18 procedures covering Indications, Contraindications, Patient Positioning, Key Instruments, and Complications:
OT PROCEDURES - Full Detail
1) JABOULAY'S OPERATION
Indications:
- Primary vaginal hydrocele (especially with thin, non-fibrotic sac)
- Hydrocele causing discomfort or cosmetic concern
- Hydrocele with thin, easily everted tunica vaginalis
Contraindications:
- Thick, fibrosed, or calcified hydrocele sac (simple excision preferred instead)
- Secondary hydrocele due to underlying testicular tumour (must treat cause first)
- Active scrotal infection
- Unfit patient (relative)
Patient Positioning: Supine, legs slightly abducted, sandbag under buttocks
Key Instruments:
- Scalpel (No. 15 blade), tissue forceps, scissors (straight + curved)
- Haemostatic clamps (artery forceps)
- Absorbable sutures (Vicryl 2-0/3-0) for eversion
- Scrotal support/dressing
Complications:
- Haematoma (most common)
- Wound infection
- Recurrence
- Reactionary haemorrhage
- Injury to epididymis or vas deferens
- Scrotal oedema
2) OPEN INGUINAL HERNIOPLASTY
Indications:
- Symptomatic inguinal hernia (direct or indirect)
- Incarcerated hernia
- Strangulated hernia (emergency)
- Patient unfit for general anaesthesia (can be done under local/spinal)
Contraindications:
- Absolute: None for symptomatic hernia
- Relative: Active groin infection, severe coagulopathy (uncorrected), extremely poor surgical fitness
Patient Positioning: Supine, slight Trendelenburg (helps reduce hernia contents)
Key Instruments:
- Scalpel, retractors (Langenbeck, self-retaining)
- Polypropylene mesh (Prolene mesh - for Lichtenstein repair)
- Non-absorbable sutures (Prolene 2-0) for mesh fixation
- Absorbable sutures (Vicryl) for closure
Complications:
- Haematoma / seroma
- Wound infection
- Chronic groin pain (ilioinguinal nerve injury)
- Recurrence (5-10% lifetime)
- Injury to vas deferens or testicular vessels → ischaemic orchitis / testicular atrophy
- Bladder injury (if sliding hernia)
- Mesh infection / migration
3) LAP TAPP INGUINAL HERNIA REPAIR
Indications:
- Bilateral inguinal hernias (major advantage over open)
- Recurrent hernia after previous open repair
- Patients wanting faster recovery / return to work
- Female inguinal hernia
- Obese patients (relative advantage)
Contraindications:
- Previous lower abdominal surgery (relative - adhesions complicate preperitoneal dissection)
- Large scrotal hernias
- Inability to tolerate pneumoperitoneum (severe COPD, cardiac disease)
- Strangulated hernia with bowel resection needed
- Uncorrected coagulopathy
Patient Positioning: Supine, both arms tucked, Trendelenburg (15°), surgeon stands on opposite side to hernia
Key Instruments:
- 10 mm camera port (umbilical), 5 mm working ports x2
- Laparoscopic scissors, dissector, graspers
- Tacker/ProTack or absorbable tacks for mesh fixation
- Polypropylene or composite mesh (10x15 cm)
- Endoscopic suture for peritoneal closure
Complications:
- Port site hernia
- Vascular injury (iliac vessels, epigastric vessels - "triangle of doom")
- Nerve injury (lateral femoral cutaneous nerve - "triangle of pain")
- Bladder injury
- Vas deferens injury
- Recurrence (comparable to open at 5 years)
- CO₂ pneumoperitoneum complications (subcutaneous emphysema, gas embolism)
4) OPEN APPENDICECTOMY
Indications:
- Acute appendicitis (classic presentation)
- Perforated appendicitis with peritonitis
- Appendicular mass or abscess after conservative management
- When laparoscopic facilities unavailable
- Incidental appendicectomy (during other open surgery)
Contraindications:
- No absolute contraindications in acute appendicitis
- Relative: Appendicular abscess/phlegmon that has resolved (may manage conservatively and do interval appendicectomy)
Patient Positioning: Supine
Key Instruments:
- Scalpel (No. 22 blade for skin incision - Lanz/Gridiron)
- Langenbeck retractors
- Babcock's forceps (to grasp appendix)
- Artery forceps, ligatures (Vicryl/chromic catgut 2-0 for mesoappendix and base)
- Purse-string suture (if burying stump - optional)
Complications:
- Wound infection (most common - 5-10%)
- Intra-abdominal abscess (pelvic, subphrenic)
- Faecal fistula (stump breakdown)
- Bowel obstruction (adhesions - long term)
- Stump appendicitis (if too much appendix left)
- Negative appendicectomy (10-20% - normal appendix found)
5) LAPAROSCOPIC APPENDICECTOMY
Indications:
- Same as open; preferred in:
- Women of reproductive age (allows exclusion of gynaecological pathology)
- Obese patients
- Diagnostic uncertainty
- Athletes / physically active patients
Contraindications:
- Generalised peritonitis with haemodynamic instability (relative)
- Periappendiceal abscess (relative)
- Previous abdominal surgery with dense adhesions
- Inability to tolerate pneumoperitoneum
Patient Positioning: Supine, slight Trendelenburg + left lateral tilt (to move bowel away from right iliac fossa)
Key Instruments:
- 10 mm umbilical port, 5 mm ports x2
- Laparoscopic graspers, scissors, electrocautery hook
- Endoloops (Roeder's loops) or endoscopic stapler for appendix base
- Endo-bag (Endobag) for specimen retrieval
- Irrigation/suction
Complications:
- Port site infection
- Port site hernia
- Intra-abdominal abscess (slightly higher than open)
- Bowel injury (electrocautery spread)
- CO₂ complications
- Conversion to open (~5%)
6) LAPAROSCOPIC CHOLECYSTECTOMY
Indications:
- Symptomatic gallstones (biliary colic, acute cholecystitis)
- Gallstone pancreatitis (after resolution)
- Mucocele / empyema of gallbladder
- Carcinoma of gallbladder (early - T1a)
- Biliary dyskinesia (acalculous)
- Gallbladder polyps >10 mm
Contraindications:
- Absolute: Gallbladder cancer suspected (advanced - T2+), inability to tolerate GA
- Relative: Previous upper abdominal surgery, Mirizzi syndrome, cirrhosis with portal hypertension, third trimester of pregnancy, severe cardiopulmonary disease
Patient Positioning: Supine, reverse Trendelenburg + left lateral tilt (French position) or surgeon between legs
Key Instruments:
- 10-12 mm umbilical port (camera), 5 mm ports x3
- Laparoscopic scissors, hook electrocautery, Maryland dissector
- Titanium clips (Hem-o-lok) for cystic duct and artery
- Endobag for specimen retrieval
- Cholangiography catheter (if intraoperative cholangiogram performed)
Complications:
- Bile duct injury (most feared - 0.3-0.5%)
- Bile leak (cystic duct stump, gallbladder fossa)
- Haemorrhage (cystic artery, liver bed)
- Retained stones in CBD
- Port site hernia
- Conversion to open (~5%)
- Post-cholecystectomy syndrome
7) FIBROADENOMA EXCISION
Indications:
- Size >3 cm
- Increasing size on serial USS
- Patient anxiety / request
- Triple assessment inconclusive
- Giant fibroadenoma (>5 cm)
- Age >35 (to exclude phyllodes tumour)
Contraindications:
- Small, stable fibroadenoma in young patient (<25 yrs) - can observe
- Multiple bilateral fibroadenomas (surgery not practical)
- High surgical risk patient
Patient Positioning: Supine, arm on affected side abducted on arm board
Key Instruments:
- Scalpel (No. 15 blade), fine tissue scissors
- Fine-toothed forceps (Adson's)
- Mosquito artery forceps
- Absorbable sutures (Vicryl 2-0/3-0 for breast tissue, 4-0 subcuticular for skin)
- Specimen pot
Complications:
- Haematoma
- Seroma
- Wound infection
- Recurrence (new fibroadenomas may develop)
- Scarring / cosmetic deformity
- Missed diagnosis (phyllodes tumour - histology mandatory)
8) CIRCUMCISION
Indications:
- Phimosis (congenital or acquired)
- Paraphimosis (after emergency reduction)
- Recurrent balanitis / balanoposthitis
- Lichen sclerosus (BXO - balanitis xerotica obliterans)
- Religious / cultural (most common worldwide reason)
- Penile carcinoma (prophylactic / therapeutic)
- Recurrent UTIs in infant boys (relative)
Contraindications:
- Hypospadias or epispadias (foreskin needed for repair)
- Bleeding disorders (uncorrected)
- Active local infection (penile cellulitis)
- Ambiguous genitalia (until evaluated)
Patient Positioning: Supine, legs straight or frog-legged in children
Key Instruments:
- Scalpel (No. 15), fine scissors
- Artery forceps, tissue forceps
- Bipolar or diathermy (careful use near neurovascular bundle)
- Absorbable sutures (Vicryl Rapide 4-0 or chromic catgut 3-0)
- Dorsal clamp (Gomco, Plastibell in neonates)
Complications:
- Haemorrhage (most common)
- Wound infection
- Meatal stenosis (especially in infants)
- Too much / too little skin removed
- Urethral injury (rare)
- Penile lymphoedema
- Buried penis (if excessive skin removed)
9) MODIFIED RADICAL MASTECTOMY (MRM)
Indications:
- Invasive breast cancer where breast conservation is not possible:
- Large tumour relative to breast size
- Multicentric disease
- Patient preference
- Previous radiotherapy to breast
- Contraindication to radiotherapy
- BRCA1/2 carriers (prophylactic bilateral mastectomy)
- Inflammatory breast cancer
- Paget's disease of nipple with underlying mass
Contraindications:
- Stage IV (metastatic) disease - palliative mastectomy only as exception
- Locally unresectable disease (T4d inflammatory - needs neoadjuvant first)
- Medically unfit patient
- Note: Breast conservation therapy (BCT) preferred when feasible
Patient Positioning: Supine, arm on affected side extended on arm board at 90°, slight lateral tilt away, shoulder roll
Key Instruments:
- Scalpel, electrocautery (diathermy)
- Langenbeck and self-retaining retractors
- Axillary dissection instruments (scissors, Lahey forceps)
- Drains x2 (axillary + chest wall - closed suction, e.g. Redivac/Jackson-Pratt)
- Absorbable deep sutures (Vicryl 2-0), skin clips or sutures
Complications:
- Seroma (most common - 30-60%, under mastectomy flap)
- Haematoma
- Wound infection
- Lymphoedema of arm (axillary dissection)
- Shoulder stiffness / restricted movement
- Nerve injuries: intercostobrachial nerve (numbness inner arm), long thoracic nerve (winged scapula), thoracodorsal nerve (weakened latissimus dorsi)
- Flap necrosis
- Phantom breast pain
10) FEEDING JEJUNOSTOMY
Indications:
- Post-oesophagectomy (standard adjunct)
- Oesophageal/gastric cancer preventing oral feeding
- Prolonged NPO status with inaccessible stomach (e.g., gastric outlet obstruction)
- Head and neck cancers with dysphagia
- Severe gastroparesis
- Trauma to upper GI tract
Contraindications:
- Bowel obstruction distal to proposed jejunostomy site
- Severe mesenteric ischaemia
- Ascites (relative - can complicate wound healing and cause leakage)
- Radiation enteritis at proposed site
- Patient with good gut function who can be fed by other means
Patient Positioning: Supine
Key Instruments:
- Standard laparotomy set (if open)
- Jejunostomy feeding tube (Witzel technique or direct tube)
- Purse-string sutures (Prolene/Vicryl)
- Securing sutures to fix jejunal loop to anterior abdominal wall
Complications:
- Tube blockage / displacement
- Wound infection around stoma site
- Jejunal volvulus around tube
- Aspiration (if tube migrates)
- Peritonitis (if leakage occurs)
- Electrolyte imbalances (refeeding syndrome)
- Diarrhoea
11) THYROIDECTOMY
Indications:
- Total thyroidectomy: Thyroid cancer (DTC, MTC, ATC), Graves' disease (refractory/contraindication to medical), large multinodular goitre, compressive symptoms
- Hemithyroidectomy: Solitary nodule for diagnosis, follicular neoplasm on FNA, unilateral benign disease
- Thyroid cancer with lymph node involvement (+ central/lateral neck dissection)
- Subtotal: Bilateral nodular disease (less common now)
Contraindications:
- Uncorrected thyrotoxicosis pre-op (must render euthyroid first with antithyroids - risk of thyroid storm)
- Uncontrolled coagulopathy
- Bilateral vocal cord paralysis (tracheostomy needed first)
- Very poor surgical fitness
- Distant metastatic disease without local compressive symptoms (relative)
Patient Positioning: Supine, neck extended (shoulder roll/sandbag under shoulders, head ring), arms tucked
Key Instruments:
- Scalpel, self-retaining retractors (Joll's thyroid retractor)
- Langenbeck retractors
- Fine artery forceps (mosquito clamps)
- Nerve monitor (intraoperative neuromonitoring of recurrent laryngeal nerve - RLN)
- Harmonic scalpel / LigaSure (energy device)
- Absorbable sutures, skin closure clips
- Drains (optional)
Complications:
- RLN (Recurrent Laryngeal Nerve) injury - unilateral: hoarseness; bilateral: stridor/airway emergency
- Hypoparathyroidism (hypocalcaemia - tetany, Chvostek's sign, Trousseau's sign)
- Haematoma (can compress airway - emergency reopening at bedside)
- Thyroid storm (inadequately prepared thyrotoxic patient)
- Hypothyroidism (requires lifelong thyroxine post total thyroidectomy)
- Wound infection
- Tracheomalacia (rare, after long-standing goitre)
12) HEMICOLECTOMY
Indications:
- Right hemicolectomy: Carcinoma of caecum, ascending colon, hepatic flexure; Crohn's disease of terminal ileum; ileocaecal TB; carcinoid tumour of appendix/caecum (>2 cm)
- Left hemicolectomy: Carcinoma of descending colon, splenic flexure; complicated diverticular disease; ischaemic colitis
Contraindications:
- Unresectable metastatic disease (relative - palliation still possible)
- Haemodynamically unstable patient (temporary stoma preferred in emergency)
- Severe malnutrition (relative - optimise first)
- Unfit patient unable to tolerate major surgery
Patient Positioning:
- Right: Supine (Lloyd-Davies position if low right)
- Left: Right lateral or supine; Lloyd-Davies for anastomosis
Key Instruments:
- Full laparotomy set, bowel clamps (Parker-Kerr, non-crushing clamps)
- Linear stapler (GIA) for bowel division
- Circular stapler (EEA) for anastomosis (or hand-sewn)
- Self-retaining retractor (Balfour or Denis-Browne)
- Drains (optional)
Complications:
- Anastomotic leak (most feared - 3-5%)
- Wound infection
- Ileus / bowel obstruction
- Haemorrhage
- Ureter injury (especially left hemicolectomy)
- Stoma-related complications (if stoma formed)
- DVT / PE
- Change in bowel habit / diarrhoea (loss of ileocaecal valve in right hemi)
13) GASTRECTOMY
Indications:
- Total gastrectomy: Proximal/diffuse gastric cancer, linitis plastica
- Subtotal (distal) gastrectomy: Distal gastric cancer, refractory peptic ulcer disease (rare now), gastric outlet obstruction
- Morbid obesity (sleeve gastrectomy - a different procedure)
- Gastrointestinal stromal tumours (GIST) of stomach
Contraindications:
- Distant metastases making resection non-curative (relative - palliation bypass preferred)
- Unfit patient for major surgery
- Unresectable tumour invading major vessels
- Severe malnutrition (needs pre-op optimisation)
Patient Positioning: Supine, slight reverse Trendelenburg, arm extended
Key Instruments:
- Full laparotomy set
- Linear stapler (GIA/TA) for gastric division
- Circular stapler (EEA 25-28mm) for oesophagojejunal anastomosis (total gastrectomy)
- Ligaclips / energy device (LigaSure) for vessel control
- Nasojejunal tube or feeding jejunostomy tube
Complications:
- Anastomotic leak (most serious - 3-8%)
- Dumping syndrome (early and late) - after distal gastrectomy/gastrojejunostomy
- Vitamin B12 deficiency (loss of intrinsic factor - total gastrectomy requires lifelong B12 injections)
- Iron and folate deficiency anaemia
- Bile reflux gastritis
- Afferent loop syndrome (Billroth II)
- Weight loss / malnutrition
- Haemorrhage
- DVT/PE
14) ABDOMINO-PERINEAL RESECTION (APR)
Indications:
- Low rectal cancer where sphincter preservation is not oncologically safe (<1 cm distal margin achievable)
- Anal canal carcinoma (squamous cell - after failed/recurrent chemoradiotherapy)
- T4 rectal cancer invading sphincter complex
- Poor baseline sphincter function pre-op
Contraindications:
- Stage IV disease with no local symptoms (relative - systemic treatment first)
- Patient unfit for major pelvic surgery
- Note: Neoadjuvant chemoradiotherapy should always be considered first to downstage and allow possible sphincter preservation
Patient Positioning: Lloyd-Davies (modified lithotomy) - supine with legs in stirrups; allows simultaneous abdominal + perineal approach by two teams
Key Instruments:
- Full laparotomy set + perineal set
- Linear stapler for sigmoid division
- Electrocautery, energy device (LigaSure/Harmonic)
- Self-retaining retractor (St Mark's, Balfour)
- Perineal retractors (Lone-Star)
- Drains (pelvic drain + perineal)
- End colostomy supplies (stoma bag, rod)
Complications:
- Permanent colostomy (inevitable - patient must be counselled pre-op)
- Perineal wound complications (delayed healing, breakdown, infection - 30-50%)
- Sexual dysfunction (autonomic nerve injury - erection, ejaculation in males; dyspareunia in females)
- Urinary dysfunction (bladder atony from pelvic nerve injury)
- Haemorrhage (presacral veins - can be catastrophic)
- Phantom rectum sensation
- DVT/PE (major pelvic surgery)
- Stoma complications (prolapse, retraction, parastomal hernia)
15) WHIPPLE'S PROCEDURE (Pancreaticoduodenectomy)
Indications:
- Carcinoma of head of pancreas (resectable - no vascular invasion of SMA/portal vein beyond 180°)
- Ampullary carcinoma
- Cholangiocarcinoma (distal CBD)
- Duodenal carcinoma
- Chronic pancreatitis (head mass / obstructed duct) - Frey's procedure preferred
- Cystic neoplasms of pancreatic head (IPMN, mucinous cystic neoplasm)
Contraindications:
- Distant metastases (liver, peritoneal)
- Major vascular encasement (SMA, coeliac axis involvement - unresectable)
- Locally advanced disease beyond surgical resection
- Very poor performance status (ECOG 3-4)
- Severe portal hypertension
Patient Positioning: Supine, slight reverse Trendelenburg, arms extended on arm boards
Key Instruments:
- Full laparotomy set
- Vascular clamps and loops (for portal vein control if needed)
- Linear and circular staplers
- Energy devices (LigaSure/Harmonic)
- Feeding jejunostomy tube
- Multiple drains (near pancreaticojejunostomy and hepaticojejunostomy)
Complications:
- Pancreatic fistula/leak (most common major complication - 10-20%)
- Delayed gastric emptying (20-50%)
- Bile leak
- Post-pancreatectomy haemorrhage
- Intra-abdominal abscess
- Wound infection
- Endocrine insufficiency (diabetes)
- Exocrine insufficiency (requires pancreatic enzyme replacement - Creon)
- DVT/PE
- Mortality: 3-5% in specialist centres
16) LATERAL PANCREATICOJEJUNOSTOMY (Puestow-Gillesby / Partington-Rochelle Procedure)
Indications:
- Chronic pancreatitis with dilated main pancreatic duct (>7 mm - "chain of lakes" on imaging)
- Intractable abdominal pain not responding to medical/endoscopic treatment
- Pancreatic duct obstruction with upstream dilatation
Contraindications:
- Non-dilated duct (<5-7 mm) - drainage ineffective; resection preferred (Beger/Frey)
- Pancreatic cancer suspected (do not drain - resect)
- Active alcohol use without commitment to abstinence (relative - pain recurrence likely)
- Unfit patient
- Ascites / portal hypertension (relative)
Patient Positioning: Supine
Key Instruments:
- Full laparotomy set
- Electrocautery for opening the duct (longitudinal ductotomy)
- Roux-en-Y jejunal loop preparation instruments
- Hand-sewn anastomosis sutures (Vicryl/PDS 3-0/4-0)
- Intraoperative USS (to locate duct if not palpable)
Complications:
- Anastomotic leak / fistula
- Pain recurrence (50% at 5 years - disease progression)
- Diabetes (progression of chronic pancreatitis)
- Pancreatic exocrine insufficiency
- Haemorrhage
- Wound infection
- Failure to relieve pain (if duct not adequately decompressed)
17) TRACHEOSTOMY
Indications:
- Prolonged mechanical ventilation (most common - ICU patients, after ~10-14 days intubation)
- Upper airway obstruction (foreign body, tumour, bilateral vocal cord palsy, trauma, angioedema)
- Facilitate tracheal/bronchial toilet (unable to clear secretions)
- Head and neck cancer surgery (prophylactic - post laryngectomy, major oral surgery)
- Burns to face/airway
- Neurological conditions causing loss of airway protection (GBS, MND, high spinal cord injury)
Contraindications (all relative):
- Coagulopathy (correct before elective procedure)
- Local infection/cellulitis at site
- Unstable cervical spine (modify approach)
- Paediatric patients (more challenging - usually surgical rather than percutaneous)
- Highly obese short neck (percutaneous - use bronchoscopic guidance)
Patient Positioning: Supine, neck extended with shoulder roll, head ring, table slightly elevated (reverse Trendelenburg)
Key Instruments:
- Scalpel, tissue scissors, dissecting scissors
- Self-retaining tracheal dilator (Bjork flap technique)
- Trousseau's or Killian's dilator
- Tracheostomy tube (cuffed, appropriate size - Shiley, Portex)
- Securing tapes/ties and stay sutures
- Percutaneous technique: Introducer needle, guidewire, Ciaglia dilators, bronchoscope
Complications:
- Early: Haemorrhage, false passage, posterior tracheal wall injury, subcutaneous emphysema, pneumothorax, tube displacement
- Intermediate: Tube blockage, infection, aspiration
- Late: Tracheal stenosis (most significant long-term), tracheomalacia, tracheo-oesophageal fistula, tracheo-innominate artery fistula (rare but fatal), persistent stoma
18) OPEN CYSTOGASTROSTOMY
Indications:
- Pancreatic pseudocyst:
- Symptomatic (pain, early satiety, nausea)
- Size >6 cm persisting >6 weeks
- Pseudocyst causing biliary or gastric outlet obstruction
- Failed endoscopic or radiological drainage
- Pseudocyst adherent to posterior gastric wall (ideal for cystogastrostomy)
Contraindications:
- Pseudocyst not adherent to stomach (cystojejunostomy preferred instead)
- Cystic pancreatic neoplasm (must rule out before draining - risk of draining a mucinous neoplasm)
- Active pancreatic haemorrhage into pseudocyst (pseudoaneurysm - requires angioembolisation first)
- Infection of pseudocyst / abscess (needs external drainage)
- Unfit patient
Patient Positioning: Supine
Key Instruments:
- Full laparotomy set
- Large-bore needle/trocar (to decompress cyst initially)
- Electrocautery for gastrotomy and cystotomy
- Sutures (Vicryl/PDS 2-0) for posterior cystogastric anastomosis
- Drains (optional)
- Specimen for histology (mandatory - to exclude neoplasm)
Complications:
- Bleeding from anastomotic margin
- Recurrence of pseudocyst
- Infection / abscess formation
- Missed cystic neoplasm (if histology not sent)
- Gastric fistula
- Pancreatitis recurrence
Quick Reference Summary Table
| # | Procedure | Key Indications | Key Contraindications | Main Complications |
|---|---|---|---|---|
| 1 | Jaboulay's | Thin-sac hydrocele | Thick fibrosed sac, secondary hydrocele | Haematoma, recurrence |
| 2 | Open Hernioplasty | Symptomatic inguinal hernia | Active groin infection | Chronic pain, recurrence, vas injury |
| 3 | LAP TAPP | Bilateral/recurrent hernia | Previous lower abdominal surgery | Vascular/nerve injury, port hernia |
| 4 | Open Appendicectomy | Acute appendicitis | None absolute | Wound infection, adhesions |
| 5 | Lap Appendicectomy | Diagnostic uncertainty, women | Dense adhesions, haemodynamic instability | Intra-abdominal abscess |
| 6 | Lap Cholecystectomy | Symptomatic gallstones | Suspected advanced GB cancer | Bile duct injury, bile leak |
| 7 | Fibroadenoma Excision | >3 cm, growing, age >35 | Small stable lump in young patient | Haematoma, missed phyllodes |
| 8 | Circumcision | Phimosis, BXO, recurrent balanitis | Hypospadias, coagulopathy | Haemorrhage, meatal stenosis |
| 9 | MRM | Breast cancer, patient preference | Stage IV (relative), unfit | Seroma, lymphoedema, nerve injury |
| 10 | Feeding Jejunostomy | Post-oesophagectomy, prolonged NPO | Distal obstruction, ischaemia | Tube displacement, peritonitis |
| 11 | Thyroidectomy | Thyroid cancer, Graves', goitre | Uncorrected thyrotoxicosis | RLN injury, hypocalcaemia, haematoma |
| 12 | Hemicolectomy | Colon cancer, Crohn's | Unresectable metastases | Anastomotic leak, ureteric injury |
| 13 | Gastrectomy | Gastric cancer, GIST | Distant mets, unresectable | Anastomotic leak, dumping, B12 def |
| 14 | APR | Low rectal cancer, anal Ca | Stage IV, unfit | Permanent stoma, sexual/urinary dysfunction |
| 15 | Whipple's | Pancreatic head Ca, ampullary Ca | Distant mets, SMA encasement | Pancreatic fistula, delayed gastric emptying |
| 16 | Lateral PJ | Chronic pancreatitis, dilated duct (>7mm) | Non-dilated duct, suspected cancer | Pain recurrence, fistula |
| 17 | Tracheostomy | Prolonged ventilation, airway obstruction | Coagulopathy (relative) | Tracheal stenosis, haemorrhage |
| 18 | Open Cystogastrostomy | Symptomatic pseudocyst adherent to stomach | Pseudoaneurysm, neoplasm not excluded | Bleeding, recurrence, missed neoplasm |
Let me know if you want more detail on any specific procedure, or if you'd like pre-op/post-op nursing care added!
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