AXILLARY ABSCESS I and D

Operation: debridement of left axillary wound

Findings: wound in left axilla after bursting of axillary abscess, filled with pus
Procedure: 1. general anesthesia given 2. Patient’s left arm, axilla and left side ofchest and neck
scrubbed and draped 3. All dead necrotic material excised and all pus drained gently taking care not to
injure the axillary vasculature 4. Wound washed with hydrogen peroxide and normal saline and cavity
packed with pyodine soaked ribbon gauze and aseptic dressing done 5. Patient woke up and moved to
recovery.

HEMORRHOIDECTOMY
OPERATIVE FINDINGS: internal hemorrhoids at 3 &7 O’clock

PROCEDURE: 1. Spinal anesthesia given. 2. Patient placed in lithotomy position with some head down tilt.
[Link] per rectal examination proctoscope placed in the anal canal findings confirmed and hemorrhoids
grasped with artery forceps and retracted outward. 4. Small v shaped incision given at base of
hemorrhoids beyond anal verge and anal mucosa separated from the muscles using gauze piece. A suture
ligature is placed at proximal aspect of vascular pedicle using vicryl 2/0. [Link] diathermy is used to excise
the haemorrhoidal bundle. 6. Repeated the procedure for other hemorrhoid.

7. Complete hemostasis ensured. 8. Anal packing done and T bandage dressing applied.

FISTULECTOMY
Operative findings: 1. internal openings at 5 & 7 0 clock 2. External openings at 5, 6 & 7 0 clock position
around 2.5 cm from the anal verge

Procedure: 1. spinal anesthesia given 2. Patient place in lithotomyposition 3. Perianal area scrubbed
and draped 4. DRE and proctoscopy done 5. Probe inserted in the tracts and taken out through internal
opening 6. Fistulous tracts excised using diathermy and all the granulation tissue curetted 7.
Hemostasis secured. 8. Cavity washed with povidone iodine and normal saline 9. Cavity packed and
aseptic dressing done.

FISTULOTOMY

operative findings: 1. internal opening at 5 O clock. External opening at 7 O clock position around 2.5cm
from anal verge

procedure: 1. spinal anesthesia given 2. patient place in lithotomy position 3. perianal area scrubbed
and drapped 4. DRE and proctoscopy done 5. probe inserted in the tracts and taken out through internal
opening 6. fistulous tracts laid open using diathermy and all the granulation tissue curretted 7.
hemostasis secured 8. cavity washed with povidone iodine and normal saline 9. cavity packed and
aseptic dressing done.
 INCISION AND DRAINAGE OF PERIANAL ABSCESS
OPERATIVE FINDINGS: a. 3x3cm perianal abscess at 5 0’clock position. b. Overlying skin erythematous.

c. No internal communication to anal canal.

OPERATIVE NOTES: 1. Spinal anesthesia given. 2. Digital rectal examination and proctoscopy
examination done to see any communication to anal canal. 3. Perianal area scrubbed and draped. 4.
Cruciate incision given at point of maximum fluctuation with scalpel blade no.11. 5. Skin edges excised
to deroof the abscess. 6. With a finger in anorectum, cavity of abscess is carefully curetted. 7. Abscess
cavity is irrigated with hydrogen peroxide and normal saline. 8. Hemostasis secured. 9. Cavity is lightly
packed with gauze. 10. Aseptic dressing done. 11. Patient moved to recovery.

LUMPECTOMY/EXCISION OF LUMP
Operation: Excision of lump

Operative findings: lump in the left breast 7x5cm in size at 10 0 clock position.

Procedure: 1. General anesthesia given 2. Left breast scrubbed and draped 3. Circumareolar incision
given at 10 0 clock over the lump. 4. Subcutaneous tissue diathermized and lump dissected from
surrounding breast tissue and excised using sharp and blunt dissection. 5. Hemostasis secured. 6.
Subcutaneous fat closed with vicryl 2-0 interrupted and skin closed with subcuticular vicryl 3-0.

EXCISION OF LUMP
Operative findings: lump in the left breast 2x2cm in size at 11 0 clock position.

Procedure: 1. General anesthesia given 2. Left breast scrubbed and draped 3. Circumferential incision
given at 11 0 clock overthe lump. 4. Subcutaneous tissue diathermized and lump excised using sharp
and blunt dissection. 5. Hemostasis secured. 6. Subcutaneous fat closed with vicryl 3-0 interrupted and
skin closed with subcuticular vicryl 3-0. 9. Aseptic dressing done.

LEFT MRM
Operation: left sided modified radical mastectomy operative findings: 1. central tumor behind nipple
areola complex slightly extending to upper outer quadrant in 2-3 0 clock position. Procedure: 1. General
anesthesia given 2. Patient placed supine with arm on the operative side extended on an arm board. 3.
Position of lump and elliptical incision marked transversely encompassing approximately 5cm of skin
around the lesion and also the nipple. 4. Patient's left side of chest and left arm scrubbed and drapped
5. elliptical incision given on previously marked site. 6. Skin flaps raised in the plane between
subcutaneous fat and mammary fat. 7. Upper flap raised to the upper limit of breast i.e. 2-3cm below
the clavicle, approximately second intercostal space. 8. lower flap raised to the lower limit of breast 9.
breast tissue dissected down until the fascia of pectoralis major. 10. Axillary contents cleared from
lateral border of pactoralis major anteriorly to anterior border of latissimus dorsi posteriorly, with
 axillary vein making upper limit of dissection. 11. Nerve to serratus anterior and thoracodorsal trunk
identified and preserved. washed with normal saline and hemostasis secured. 12. 14french radivec drain
inserted for flap and 16 french radivec drain for axilla and drains secured with silk sutures. 13.
Subcutaneous fat closed with vicryl interrupted and skin closed with staples. 14. Aseptic dressing done.

LAPAROSCOPIC CHOLECYSTECTOMY
Findings: 1) Gall bladder with multiple stones 2) Normal Calot’s triangle anatomy. Procedure: 1) General
anesthesia given. Patient scrubbed and draped from the nipples above to supra pubic area below and
mid axillary line laterally on left and to posterior axillary line on right. 2) Nasogastric tube passed and
stomach deflated. 3) Pneumoperitoneum established via open method. 10 mm infra umbilical incision
given. Trocar inserted. insufflation using CO2 and insertion of camera done. Intra abdominal pressure
maintained of 10-14mmHg. 4) The patient is placed in reverse Trendelenburg position slightly rotated to
the left. 5) Placement of three other ports .One 10mm port in the subxiphoid position with the intra-
Abdominal portion located to the right of falciform ligament. A 5mm port 2 finger breadths below the
right costal margin and close to midclavicular line. A 5mm port laterally along the anterior axillary line. A
laparoscope is used to explore the abdomen for adhesions and potential injuries that may have occurred
during port placement. 6) A crocodile forcep is inserted through the lateral 5mm to retract fundus of gall
bladder towards diaphragm. Neck of gall bladder is retracted by plain forceps towards right iliac fossa
Exposing calot’s triangle using the middle 5mm port. 7) A hook cautery is used to carefully incise the
peritoneum overlying the calot’s triangle both anteriorly and posteriorly 8) All remaining connective
tissue is dissected out of calot’s triangle using blunt dissection by marryland dissector and hook
cautery as needed. 9) Clips are then placed around the cystic duct – two below and one above and
one clip around the cystic artery is placed. 10) Scissors are then used to cut the duct and hook
diathermy used for cystic artery. 11) The gall bladder is then dissected off the liver and a bag is used
to remove it out of the abdomen through the subxiphoid port. 12) Homeostasis secured. 13) The
ports are removed and gasstopped to remove free gas. 14) The fascial defect is closed at the
umbilicus and subxiphoid with Vicryl 0 on J needle. Skin closed with vicryl 3/0. 15) The rest of the
ports are closed at the skin with vicryl 3/0
16) Aseptic dressings are placed and the patient woke

After aseptic measure (ASM). 4 port technique used. Pneumoperitoneum created. Pathology identified.
Calot’s triangle dissected and cystic duct and artery clamped and divided. Gallbladder dissected off the
liver bed. Gallbladder removed. Wound closed in reverse manner. Aseptic dressing done (ASD)
 PARAUMBILICAL HERNIA REPAIR
OPERATIVE FINDINGS: Paraumblical hernia with defect of almost 6cm. Contents of sac: viable gut
PROCEDURE: 1) Abdomen scrubbed and draped from the level of nipples above to groin below. 2)
Elliptical incision given including the umbilicus. 3) Sharp dissection through skin and subcutaneous
tissue to underlying fascia done. 4) Hernia sac identified and opened and contents visualized and
returned to peritoneal cavity. 5)5cm clearance of fascial defect done with careful finger sweep in
sub fascial layer. 6) Primary repair of fascial defect done with prolene 1. 7) Onlay placement of
prolene mesh 15x15cm done and stabilized with prolene 1. 8) Redivac drain 16 Fr placed and
secured with silk suture. 9) Subcutaneous fat closed with vicryl 2/O 10) Skin closed by skin stapler
11) Aseptic dressing done12) Patient woke up and moved to recovery.

INGUINAL HERNIA REPAIR

Operative Findings: 1) Right sided Inguinal Hernia (Indirect) 2) Contents of hernia sac: viable omentum.
Operative Notes: 1) Spinal anesthesia given. The patient scrubbed and draped from the umbilicus above
to the mid thighs involving the penis and scrotum and to the right anterior superior iliac spine laterally.
2) Oblique inguinal incision made. 3) The skin along with the fat and fascia opened up with securing
hemostasis. External oblique aponeurosis and superficial inguinal ring identified. External oblique
aponeurosis incised in the line of its fibers and then split and structures beneath carefully separated
from its deep surface. 4) Ilioinguinal nerve identified and divided. 5) Swab on stick used to remove the
adherent fascia from the inguinal ligament inferiorly to the conjoint tendon superiorly. 6) The spermatic
cord lifted up using pubic tubercle as the landmark. 7) Indirect inguinal hernia seen coming from deep
inguinal ring. Hernia sac opened and contents visualized to ensure that no incarcerated bowel is present,
omentum returned to peritoneal cavity. 8) Sac is then ligated with vicryl 3/0 and amputated.
9) Polyprolene mesh 6x11cm placed on posterior wall and secured with prolene 2/0 stitches. The
external oblique aponeurosis closed using a running continuous stitch in lateral to medial direction and
the fat and fascia closed with Vicryl 2/0. 10) The skin closed with Vicryl 3/0 subcuticularly. 11) Aseptic
dressing applied. Patient moved to recovery room.

LEFT NAIL AVULSION

operative findings: left sided ingrowing toe nail procedure: 1. left foot scrubbed and draped 2. local
anesthesia given with inj xylocaine 3. left toe nail avulsed with straight artery forceps 4. lateral margins
of the nail bed curretted 5. aseptic dressing done with sofra tulle.
 SUBTOTAL THYROIDECTOMY
OPERATIVE FINDINGS: Multinodular goiter

PROCEDURE: 1. General anesthesia given. 2. Patient placed supine with a sand bag between the
shoulders and a ring under the head to extend the neck. 3. Table tilted up 15 o at head end to reduce
venous engorgement(reverse Trendelenburg). 4. A skin crease incision is made in the neck 2 finger
breadths above the sternal notch. 5. Incisioned is deepened throughplatysma and to the lateral border
of the sternocleidomastoid muscles. 6. Hemostasis achieved using diathermy and tying larger vessels
with vicryl. 7. Platysma muscle of the upper flap lifted upwards with allis forceps, dissecting using
coagulation diathermy in the sub platysmal plane, taking care of the anterior jugular veins. 8. Upper flap
raised as far as the thyroid cartilage. 9. Similarly lower flap raised as far down as the sternal notch. 10.
Joll’s retractor inserted to platysma and subdermal tissues of each flap and opened fully to expose strap
muscles. 11. Pale midline raphe identified between the strap muscles and incised along it using
diathermy. 12. Strap muscles separated and lifted with allis forceps.
13. Tissue plane created between strap muscles and the thyroid gland by dividing the flimsy layers of
fascia. 14. Allis removed and replaced with langenbeck retractors. 15. Middle thyroid veins identified
and divided. 16. Both superior thyroid poles ligated, close to the gland to avoid injury to superior
laryngeal nerve branches. 17. Inferior thyroid artery identified and tied in continuity, lateral to
recurrentlaryngeal nerve avoiding damage to the nerve. 18. Isthmus divided and each lobe mobilized
laterally 19. Tips of artery forceps applied to the capsule from the lateral aspect around the periphery
of the segment to be resected, demarcating the outer edge. 20. Each lobe sliced across from lateral
edge towards trachea using a scalpel, leaving intact posterior capsule with the attached remnant of
thyroid gland. 21. Thickest part of the remnant left laterally so that it can be folded over medially ,
allowing lateral capsular edge to be sutured to medial capsule using vicryl. 22. Hemostasis secured using
bipolar and suture ligation. 23. Strap muscles approximated using vicryl suture. 24. Radivac drain placed
through a separate stab wound and secured to skin with silk suture. 25. Platysma muscle closed with
continuousvicryl suture. 26. Skin closed with subcuticular prolene suture. 27. Aseptic dressing done.
 EMERGENCY APPENDECTOMY

OPERATIVE FINDINGS: ACUTE APPENDICITIS

After all aseptic measures, Gridiron incision given. Skin subcutaneous tissues incised. External
oblique aponeurosis is cut in the line of incision. Internal oblique split in the line of fibers.
Peritoneum grasped between two artery forceps, pinched between thumb and fingers to check
for any bowel presence. Peritoneum cut in the line of incision. Tenia coli identified and followed
till the base of appendix. Index finger is hooked around base of appendix to deliver it from
wound. Meso-appendix ligated and divided in 2 to 3 bites till the base of appendix.
Appendicular base is crushed 5 mm away from caecum and is reapplied 5 mm away from initial
site of crushing , ligated with vicryl 2/o at the site of first crushing. Appendix is divided between
suture and clamp. Exposed mucosa of appendicular stump is mopped with pyodine.
Hemostasis secured. Peritoneum closed with vicryl 2/0 continuous suture. Internal oblique
closed with vicryl 2/ 0 interrupted suture. External oblique closed with vicryl 2/0 continuous
suture. Fat closed with vicryl 3/ 0 interrupted suture. Skin closed with prolene 2/0 vertical
[Link] dressing done.
 SEBACEOUS CYST
Operation: Sebaceous cyst excision
Operative findings: Sebaceous cyst on anterior chest wall in midline at the level of nipples
Procedure: 1. patient placed supine 2. Anterior chest scrubbed and draped 3. Local anesthesia infiltrated
by injection xylocaine with adrenaline 4. Elliptical incision given over the swelling including the punctum
5. Swelling dissected from surrounding tissue using sharp and blunt dissection 6. Swelling excised as
whole 7. Cavity washed with normal saline, hemostasis secured and again washed with povidone iodine
8. Subcutaneous fat closed with vicryl 3-0 interrupted and skin closed with prolene3-0 mattress sutures
9. Aseptic dressing done 10. Patient moved to recovery.

EXCISION OF LIPOMA
OPERATIVE FINDINGS: A large encapsulated lipoma of about 10 X 8 cm size right shoulder.

OPERATIVE PROCEDURE: 1) General anesthesia [Link] scrubbed and draped on right shoulder. 2)
Elliptical incision given on lipoma 3) skin separated fromlipoma using scissors, diathermy and artery
forceps as needed. 4) Lipoma excised. 5) Hemostasissecured. 6) Skin closed with subcuticular stitch
with vicryl 2/0. 8) Aseptic dressing done.

OPERATION: AMPUTATION OF LEFT BIG TOE

Findings: left big toe gangrene procedure: [Link] anesthesia given 2. after all aseptic measures incision
given along the demarcation between live and dead skin 3. whole of dead and necrotic part excised 4.
margins refreshed till bleeding 5. hemostasis secured 6. wound washed with pyodine, hydrogen
peroxide and normal saline 7. wound packed and aseptic dressing done
 EXPLORATORY LAPROTOMY+ RELEASE OF ADHESIONS+ STRICTUREPLASTY
Operative findings: 1. multiple dense adhesions in distal ileal loops 2. Stricture in terminal ileum
procedure: 1. general anesthesia given 2. Patient scrubbed and draped from level of nipples above to
groins below 3. Midline incision given 4. Subcutaneous fat divided and linea alba reached and divided
[Link] incised and above findings noted 6. Ileal adhesions released using sharp and blunt
dissection 7. Stricture incised vertically and stitched transversely 8. Leak and patency checked 9.
Mesenteric lymph node removed for histopathology 10. Peritoneal cavity washed with normal saline
and suction done 11. Rectus sheath closed with prolene 1 12. Subcutaneous fat closed with vicryl 2-0
and skinclosed with staples. 13. Aseptic dressing done.

OPERATION: EMERGENCY INGUINAL HERNIA REPAIR + RESECTION AND ANASTOMOSIS

Operative Findings: 1) Right sided strangulated indirect Inguinal Hernia 2) Contents of hernia sac:
gangrenous 8cm loop of distal ileum around 35cm from ileocecal junction. 3) a band constricting that
bowel loop in upper portion of scrotum.

Operative Notes: 1) Spinal anesthesia given. The patient scrubbed and draped from the level of nipples
above to the mid thighs involving the penis and scrotum and to the right anterior superior iliac spine
laterally. 2) Oblique inguinal incision given. 3) The skin alongwith the fat and fascia opened up with
securing hemostasis. External oblique aponeurosis and superficialinguinal ring identified. External
oblique aponeurosis incised in the line of its fibers and then split and structures beneath carefully
separated from its deep surface. 4)Ilioinguinal nerve identified and divided.5) Swab on stick used to
remove the adherent fascia from the inguinal ligament inferiorly to the conjointtendon superiorly. 6)
The spermatic cord lifted up using pubic tubercle as the landmark. 7) Indirect inguinal hernia sac opened
and all fluid that was coming from the distal sac was aspirated. Bowel loops withdrawn from the distal
sac and warm saline soaked abdominal sponges applied, gangrenous bowel resected and ileoileal,
isoperistaltic anastomosis done via suture about 25cm from ileocecal junction. Inguinal incision
extended obliquely towards right side. Internal ring also widened laterally andBowel returned to
peritoneal cavity. 8) Sac is then ligated with vicryl 3/0 and amputated. Right orchidectomy done and
cord divided at level of internal ring. 9) internal ring closed with vicryl and The external oblique
aponeurosis closed using a running continuous stitch in lateral to medial direction and the fat and fascia
closed with Vicryl 3/0. 10) The skin closed with Vicryl 3/0. 11) Aseptic dressing appl
Most common post-operative medication
1. Inj. 5% D/W x 1L x iv x BD
2. Inj. 2Sum x 2g x iv x BD
3. Inj. Toradol x 30mg x iv x BD (8-8)
4. [Link]-P + Metacolon x iv x TDS (6-2-10)
5. [Link] x 40mg x iv x BD

Add inj. Flagyl x 500mg x iv x TDS (in perianal surgeries and laparotomies, appendectomy)
Inj. R/L x 1L x iv x BD may also be given.