Surgical Techniques

Surgical Techniques, 2
Advanced Medical Skills
ADVANCED MEDICAL SKILLS 89

Preface
The second part of Surgical Techniques is the subject-matter of the Advanced Medical Skills course. In these mod-
ules, the Institute of Surgical Research introduces surgical principles and techniques, and advanced interventions
such as surgical operations, e.g. laparotomy, appendectomy, intestinal resection, bowel anastomosis, thoracocentesis
and thoracotomy, to interested students. These procedures are taught in simulated real-life, clinical surroundings and
circumstances.
This curricular structure is used to teach and update scientic and medical ndings relevant to surgical practice,
to enhance clinical reasoning and decision-making, and to provide individual feedback and career advice. Typical fu-
ture careers of participants of this course include surgery and surgical specialties, such as gynecology, head and neck
surgery, neurosurgery, oncology, ophthalmology, orthopedics, plastic surgery, thoracic surgery, urology, vascular sur-
gery, anesthesiology, emergency medicine, critical care and cardiology.
The goals are to foster skills-based decision-making, and to broaden the correlation of physiology, anatomy and
pharmacology to acute clinical care. Emphasis is placed on procedures, critical thinking and the assessment of skills,
in order to develop the knowledge and skills to support a career choice in those specialties in which expertise in surgi-
cal anatomy is critical.
90 ADVANCED MEDICAL SKILLS

I. LAPAROTOMY
I. Laparotomy the tumor). Two other, fatal operations followed:

Billroth was stoned on the streets of Vienna.
We took out fteen pounds of a dirty, gelatinous 1885 Billroth II (pylorus cc): Successful operations
looking substance. After which we cut through the fal- were achieved.
lopian tube, and extracted the sac, which weighed sev-
en pounds and one half In ve days I visited her, and Today, emergency admissions account for 50% of
much to my astonishment found her making up her bed. the general surgical work load and abdominal pain is
(McDowell E. Three cases of extirpation of diseased the leading cause of 50% of emergency admissions. It
ovaria. Eclectic Repertory Anal Rev. 1817; 7:242244.) should be noted that 70% of the diagnoses can be made
on the basis of the history alone, and 90% of the diagno-
Terms and denitions ses can be established if the history is supplemented by
Laparo or lapar (Greek: , ) means physical examination. The expensive and complicated
the soft part of the body between the ribs and the hip; it diagnostic tests and instrumental procedures often (>
denotes the ank or loins and the abdominal wall. This 50%) merely conrm the results of the anamnesis and
term is sometimes used loosely (and incorrectly) in ref- physical examination (!).
erence to the abdomen in general. Laparotomy therefore Abdominal pain is frequently (35%) aspecic; it can
means a surgical incision through the ank; less cor- be caused by viral infections, bacterial gastroenteritis,
rectly, but more generally, it is an abdominal section at helminths, irritable bowel syndrome, gynecological dis-
any point to gain access to the peritoneal cavity. eases, psychosomatic pain, abdominal wall pain, iatro-
genic peripheral nerve lesion, hernias or radiculopathy.
The frequency of acute appendicitis and ileus is 1517%;
1. History of abdominal surgery they are followed in frequency by urological diseases
(6%), cholelithiasis (5%) and colon diverticulum (4%).
1809 On Christmas morning, Dr. Ephraim McDow- The frequency of abdominal traumas, malignant dis-
ell (17711830) in Danville (Kentucky, USA) eases, peptic ulcer perforation and pancreatitis is 23%,
successfully removed an ovarian tumor from while that of rupture of an aorta aneurysm, inamma-
Mrs. Crawford without anesthetic or antisep- tory bowel disease, gastroenteritis and mesenteric isch-
sis. The risk of fatal infection was very high emia is < 1%.
the operation was bitterly criticized.
1879 Jules mile Pan (18301898) opened the ab- 2. Technical background of
domen of a patient with cancer of the pylorus.
The diseased section was cut out; the remain-
laparotomies
der was sewn to the duodenum. The patient
died 5 days later. Abdominal incisions are based on anatomical prin-
ciples.
1880 Ludwig Rydyger (18501920) carried out the same They must allow adequate access to the abdomen.
procedure, but it had been planned in advance; They should be capable of being extended if required.
the patient died within 12 hr, of exhaustion. Ideally, muscle bers should be split rather than cut;
nerves should not be divided.
1881 Christian Albert Theodor Billroth (18291894) The rectus muscle has a segmental nerve supply. It
performed a successful operation (the patient can be cut transversally without weakening a dener-
died 4 months later due to the propagation of vated segment. Above the umbilicus, tendinous in-
tersections prevent retraction of the muscle.
3. Basic principles determining

the type of laparotomy
The disease process
The body habitus
The operative exposure and simplicity
Previous scars and cosmetic factors
The need for quick entry into the abdominal cavity

I. LAPAROTOMY
4. Recapitulation: Anatomy of 5. Principles of healing of

the abdominal wall laparotomy
Patient risk factors that negatively aect wound
healing:
Diabetes and obesity
Poor nutrition
Prior radiation or chemotherapy
Age
Alcohol
Ascites and malignancy
Immunosuppression
Coughing, retching
Hospital factors that aect wound healing negatively

Long operations
From left to right: 1. the linea alba; 2. the linea semilu- Along period of hospitalization preoperatively
naris; 3. the lig. arcuatum; and 4. the abdominal projec- Drains through incision
tion of the lig. inguinale. During laparotomy, dierent Shaving prior to surgery
anatomic structures are cut in the upper or lower ab- Type of suture
dominal regions at various distances from the midline Closure technique
(anterior vs lateral regions). During a midline incision,
the following tissue layers and structures are divided:
6. Prevention of wound
the skin,
the supercial fascia (Campers),

complications
the deep fascia (Scarpas),
the anterior rectus sheath, The scalpels should not be the same for the skin and
the rectus abdominis muscle deep incisions.
the posterior rectus sheath down to arcuate line, A scalpel should be used to cut skin and fascia and
the transversal fascia, not diathermy; the infection rate after diathermy is
the extraperitoneal connective tissue, twice as high.
the peritoneum. Deep sc. sutures should be avoided, but absorbable
synthetic material (e.g. 4.0 Dexon) may be used sub-
Recapitulation: Important things about nerves cutaneously to decrease tension on the skin.
Transverse incision is least likely to injure nerves. Use of catgut (for fascia or sc. suturing) should be
The iliohypogastric (ih) and ilioinguinal (ii) nerves avoided.
are sensory: Contaminated or dirty wounds:
ih injury leads to a loss of sensation in the skin delayed closure,
over the mons; staples with saline-soaked gauze.
ii injury leads to a loss of sensation in the labia Opening of a bacteria-containing organ:
majora. delayed closure,
Both ih and ii nerves supply the lower bers of the irrigation of all layers,
internal oblique and transverses; if divided, these - monolament, nonabsorbable suture,
bers undergo denervation, which can increase the systemic antibiotics 30 min before operation or as
risk of inguinal hernia. soon as possible, and repeat in a prolonged case.

II. INCISIONS
II. Incisions Disadvantages: The scar may be wide and not beau-
tiful, with a possible increase in hernias and dehis-
cence with the midline.
The term incision originates from the Latin (in + cidere
incisio). An incision can be longitudinal, oblique or Paramedian incision
transverse. The most important types are demonstrat- The site is parallel to and ~ 3 cm from the midline.
ed in association with abdominal operations; the prin- The following structures are divided: skin anteri-
ciples are identical in the other body regions (extremi- or rectus sheath (the m. rectus is retracted laterally)
ties, chest, neck, etc.). posterior rectus sheath (above the arcuate line)
transversalis fascia extraperitoneal fat peritone-
um. Closure is performed in layers.
1. Longitudinal incisions Indication: If excellent exposure is needed to one
side of the abdomen or pelvis.
Advantages: A lower incidence of incisional hernias.
Disadvantages: It takes longer to make and close this
incision, there is an increased risk of infection, and
intraoperative bleeding, and a risk of nerve damage;
if sited beside the midline, and it can compromise
the blood supply in the middle.
1. medin
4 2
2. fels medin
3. als medin
4. j.o. paramedin
5. McEvedy
2. Oblique incisions
1
3 5
1. Midline; 2. supraumbilical (upper midline); 3. in- 1. Kocher

2. McBurney
fraumbilical (lower midline); 4. right paramedian; 5. 1 4
3. b.o. inguinalis
4. thoraco-abdominalis
McEvedy preperitoneal approach for inguinal and fem-
oral hernia repair (McEvedy PG: Femoral hernia. Ann R
Coll Surg Engl, 1950).
2
1.1. Characteristics of longitudinal 3
incisions
(1). Kocher incision for cholecystectomy (sec. Theodor
Median incision Kocher (18411917), Nobel Prize for medicine and
This was the commonest abdominal intervention be- physiology in 1909, mainly for thyroid surgery); (2).
fore the era of minimally invasive surgery. The umbi- McBurney incision for appendectomy (after Charles
licus and the falciform ligament above the umbilicus McBurney (18451913), who performed his rst op-
should not be incised. Meticulous, careful handling eration for appendicitis in 1897); (3). left inguinal; (4).
of bleeding is necessary in the supercial layers before thoraco-abdominal
the peritoneum is opened. The urinary bladder can be
reached through the Retzius space (spatium retropu-
bicum Retzii); if there has previously been an opera-
tion in this eld, a more caudal entry is necessary (the 2.1. The basic type of oblique
chance of scar formation and adhesions is less). incisions
Advantages: There is excellent exposure to the abdo-
men and pelvis, which can easily be extended, and
also rapid entry into the abdominal cavity; the mid- Indications for McBurney muscle-splitting incision
line is the least hemorrhagic incision, and is easy to (see later): Appendicitis, pelvic abscess and extra-
perform; the linea alba is the guide to the midline. peritoneal drainage.

II. INCISIONS
3. Transverse incisions may weaken the strength of the wound healing. If

extended past the m. rectus, it can damage the ih
and ii nerves.
Maylard incision: This gives excellent exposure to
the lower pelvis; it is used for radical pelvic sur-
gery; it is a true transverse muscle-cutting inci-
sion, 38 cm above the symphysis.
Cherney incision: This is like a Pfannenstiel inci-
1. Gable sion, but divides the m. rectus at the tendinous in-
2. harnt rcsmetszs
1 3. Lanz sertion to the symphysis. It gives excellent access
4. Maylard
5. Pfannenstiel
to the space of Retzius. During closure, re-attach-
2 6. Cherney ment of muscle tendons to the rectus sheath, and
not the symphysis, should be performed in order
3
to avoid osteomyelitis.
4 Rockey Davis (Elliot) incision: This alternative to
5
6
the McBurney incision, extends to the lateral bor-
der of the rectus (it was described rst by JW El-
liot in 1896, then by AE Rockey in 1905, and -
1. Gable incision, 2. transverse muscle splitting, 3. Lanz nally by GG Davis in 1906).
incision, 4. Maylard incision, 5. Pfannenstiel incision, 6. Lanz incision: This is a special incision at the
Cherney incision right fossa iliaca. As compared with the McBur-
ney incision, it is transverse, more medial toward
the rectus, and closer to the iliac crest (spina ili-
3.1. Basic characteristics of aca anterior superior), and gives better cosmet-
transverse incisions ic results. Due to its transverse direction, the ih
and ii nerves can be damaged, and the incidence
of hernia is higher. The main indication is expo-
Advantages: These incisions give the best cosmetic sure of the appendix and cecum; the mirror im-
results, they give a much stronger scar than midline age (left iliac fossa) can be used for the left colon
incisions and less painful than longitudinal inci- (not for the rectum).
sions, and there is less interference with respiration.
There is no dierence in dehiscence rate.
Disadvantages: They are more time-consuming, and 4. Special extraperitoneal
more hemorrhagic; nerves are sometimes divided,
spaces are opened and there is a potential for hema-
incisions for staging
tomas; upper abdominal access is limited.
Main types: J-shaped incision: 3 cm medial to the iliac crest; this
Pfannenstiel incision: For gynecological indica- allows the extraperitoneal removal of para-aortic
tions. Advantages: Most wound security (in pelvic nodes; it can also be left-sided; but the right is easier.
incisions), least exposure, usually 10-15 cm long. Sunrise incision: 6 cm above the umbilicus, per-
Disadvantages: Separates the perforating nerves mitting the extraperitoneal removal of para-aortic
and small vessels from the ant. rectus, and this nodes, and allowing immediate irradiation.

III. LAPAROTOMY IN SURGICAL TRAINING
III. Laparotomy in has been opened, the incision can be lengthened

both cranially and caudally if necessary and can be
surgical training quickly closed. The disadvantages are that the com-
mon aponeurosis of six dierent strong at abdom-
inal muscles is cut, the statics of the abdominal wall
Median laparotomy is indicated when the whole ab- is greatly impaired, and this predisposes to wound
dominal part of the gastrointestinal tract should be ex- disruption and scar hernia often occurs.
plored. This will be a task in the surgical techniques The rst step is the scrub preparation of the opera-
practicals (the following operative description is related tive eld from the xyphoid process to the symphy-
to animal (e.g. pig) interventions, in which the steps are sis; draping should be performed as described ear-
identical to those of human operations). lier. The midline is shown by the umbilicus; two
laparatomy sponges are placed, one on each side of
the planned incision. Generally a short, 1015-cm-
1. General rules long incision is made, partly above and partly below
the umbilicus, going round the umbilicus at a dis-
Anesthesia tance of 12 cm from the left (not to injure the falci-
Method: General anesthesia. form ligament and the ligamentum teres hepatis).
Equipment: Typical monitors, a respirator and a In the rst phase of the operation, the skin and the
warming blanket. Insertion of a Foley catheter, and sc. fat, and then the aponeurosis of the linea alba are
application of an electrodispersive pad. The anesthesi- cut. The linea alba is a line-like sheet some tenths
ologist will insert a nasogastric tube after intubation. of a mm thick below the umbilicus, while it is wid-
er, strong and tendinous above it. The incision cuts
Positioning the posterior rectus sheet, transversal fascia, preperi-
Supine, with arms on armboards. toneal fat and parietal peritoneum. Below the umbi-
Special considerations: High-risk areas (for geriatric licus, the arcuate linea (linea semilunaris Douglasi)
patients, particular attention should be paid to the borders the area below which there is no rectus sheet.
skin and joints). After the skin incision, Doyen clamps are placed on
the wound edges and the wound towels. The sc. fat
Skin preparation is usually cut with a diathermy pencil; bleeding can
Method of hair removal: Clippers or wet, with a razor. be stopped by compression and, if necessary, by lig-
Anatomic perimeters: Traditionally from the nipple atures and stitches, or the preventive handling of
line across the chest from the table side to the table bleeding is used. Recapitulation:
side to mid-thigh.
Solution options: Betadine (povidone-iodine) or an
alternative (e.g. Hibiclens in USA).
Draping/incision
In explorations, usually 4 towels (USA: a laparoto-
my T-sheet) are used in the midline (but the isola-
tion depends on the location of the lesion; it could
be paramedian or oblique, etc; see above).
Supplies
General: Blades (3) #10 and (1) #15, scissors, forceps, elec-
tric unit pencil, suction tubing, hemostats (Pan, all sizes),
staples (optional), retractors (Gosset) and sutures (ample
supply of free ties; sizes 2-0 and 3-0 are most common).
Specic: Catheters, drains, etc.
2. Middle median laparotomy

a. A ligature is applied to cuts, or bleeding vessels if the
This can be applied when the diagnosis is uncertain. bleeding cannot be stopped by compression. Cut ves-
Its advantages are that a large area can be examined sels are grasped with hemostatic clamps (Pan or mos-
through a small incision and, after the abdomen quito). The position is checked by wiping o the blood.

If the grasping is not successful, a second hemostat The incision is deepened until the linea alba is reached,
is placed deeper. The vessel is then ligated below the the linea is then picked up with two tissue forceps
clamp. After the rst half-hitch has been tied, the he- above the umbilicus and a small incision is made be-
mostat is removed and the second half-hitch is tied. tween them (this can be done with Mayo scissors). The
opening is then lengthened cranially and caudally with
Mayo scissors while the abdominal wall is lifted up.
If the incision is made exactly in the midline, the
rectus sheet will not be opened, and the muscles will
not be severed. Above the umbilicus, care should be
taken not to injury the ligamentum falciforme hepa-
tis. The thick, fatty ligament can be clamped with
two Pan hemostats and cut between them, a better
exploration being achieved in this way.
The peritoneal cavity is isolated from the sc. layer by mak-
ing a second draping. Two laparotomy sponges are placed
on each side of the incision and fastened to the edges of
b. Preventive hemostasis: The vessel to be cut is closed the peritoneum with Mikulicz clamps on both sides.
with two hemostats in advance. The vessel is sepa- The abdominal wall is elevated with the surgeons in-
rated between them, and the two vessel ends are dex and middle ngers or with the help of the assis-
then ligated separately. tant, and the incision of the linea alba is lengthened
with Mayo scissors (or a diathermy knife) both cra-
nially and caudally to the corners of the skin wound.
During this, the peritoneum edges are xed to the
sponges with Mikulicz clamps.
A Gosset self-retaining retractor is placed into the
abdominal wound. The greater omentum or intes-
tines should not be allowed to come between the
jaws of the retractor and the abdominal wall. The
abdominal organs can be moved only with warm sa-
line-moistened laparotomy sponges.
c. Suture for hemostasis: A double, 8-form stitch is After median laparotomy, the following organs can
placed below the bleeding vessel, and the thread is be examined: 1. the greater omentum; 2. the spleen;
knotted. This suture is applied if a hemostat cannot be 3. the liver, gall bladder and bile ducts; 4. the stomach;
used, e.g. in the cases of vessels that are thin-walled or 5. the small intestine and mesenteric lymph nodes; 6.
lie in a fascia layer, or retract deep into the tissues. the appendix (cecum); 7. the large intestines; 8. the
pancreas; 9. the adrenal glands; and 10. the kidneys.
When the sc. connective tissues are divided, the The abdominal wall is closed in layers. Sutures of ap-
wound edges are lifted up with two tissue forceps or propriate size should be selected to close the dier-
clamps, and the tissues are cut transversally, layer by ent layers, and the wound edges should be exactly
layer with Mayo scissors. approximated. It should be checked that no foreign
body has been left in the peritoneal cavity. All wound
towels, sponges and instruments should be count-
ed. During abdominal operations, sponges clamped
with an instrument (a sponge-holding clamp) can be
used only for wiping, and instruments are placed on
the ends of laparotomy sponges.
The Gosset self-retaining retractor is removed, and the
laparotomy sponges isolating the peritoneal cavity are
released from the Mikulicz clamps and removed, but
the edges of the peritoneum are clamped again.
The wound of the peritoneum is closed with a half-cir-
During the blunt dissection of tissues, the closed tips cle muscle needle, with a continuous running suture (in
of Mayo scissors (or Pan, dissector) are pushed into pigs with #40 linen thread). Tissue forceps can be used
the tissues. The tissues are dissected by the opening for the rst stitch, but in most cases the wound of the
of the instrument with its blunt outer edges. These peritoneum can be well explored with Mikulicz clamps.
steps are repeated as necessary. Suturing is usually done towards the umbilicus; the rst

stitch is inserted at the cranial wound corner, but it can Wound irrigation
also be performed in the opposite direction, i.e. toward Irrigation with physiological saline to prevent infec-
the xyphoid process. If the abdominal wall is closed in tion (motto: The solution to pollution is dilution).
multiple layers, the rst row of stitches closes the poste- Irrigation with antiseptic solution (e.g. 1% povi-
rior rectus sheet together with the peritoneum. done-iodine) is eective, but can be cytotoxic (e.g.
The assistant ties a knot on the short free end of broblasts can be damaged).
the thread. He/she keeps the suture under continu-
ous tension with his/her right hand and helps with Closing the skin
the closing of the wound edges. When the peritone- None of the methods (wound clips, suturing, etc.) is
um has been closed, only one-third of the thread is substantially better than the others.
pulled through the wound and a doubled thread is To cover an abdominal skin wound, Opsite, Telfa, etc. can
left on the other side. The single and double ends of be applied; the bandage can stay in place for 23 days.
the thread are knotted and cut short. In the event of irradiation, abdominal clips should
The anterior rectus sheet and sc. wound are closed stay in the wound longer.
with interrupted sutures. The skin is closed with Do-
nati stitches, using a skin (1/4 or 3/8) needle and #40 Special case: the obese patient
linen thread. The wound is disinfected with Beta- According to international standards, a subject whose
dine and covered with a bandage. body weight exceeds the ideal by 2530% is overweight;
an excess of 3060% means that the subject is obese; in
extreme obesity the body weight exceeds the ideal by
3. Some important details 100%. The obesity is morbid if the weight excess is
greater than 130%.
The principles of closing the fascia
The fascia should be closed with the minimum num-
ber of stitches, at least 1 cm from the edges, since ne-
crosis may occur (each stitch 1 cm from another and
from the edges).
Each stitch should be closed with the same strength;
the wound edges should only be approximated (!);
sewing in fat or connective tissues should be avoided
(except in cases of en masse closure).
The Smead Jones technique involves a far to far,
near to near suture (en masse far stitches on both
sides, then near stitches involving the fascia only).
The healing tendency is theoretically good, and this
technique decreases tension, but it is time-consum-
ing and rarely used in clinical practice. The Pickwick syndrome received its name after Joe, the
somnolent, red-faced, fat boy character of Charles Dickens.
It was given by Sir William Osler (1918): A remarkable phe-
nomenon associated with excessive fat in young persons is an
uncontrollable tendency to sleep like the fat boy in Pickwick.
Modied routine in operations on obese patients

Extensive cleansing of the umbilicus and preopera-
tive bath(s)
50008000 U/12 h heparin 2 h before surgery
Drainage Elastic bandage and stockings
This may be passive or active (see earlier; the passive Removal of abdominal hair with an electric razor only
drain is never brought out in the line of the incision A very extensive scrub preparation (under skin
(danger of infection!). wrinkles also), pulling the pannus caudally
The most frequent indications are infection, oozing, Transverse incisions should always be made far from
and the need to eliminate a cavity. the wet, warm fatty skin wrinkles (duplicates)
For clean wounds, the prophylactic use of drainage En masse closure with a continuous running suture
can be controversial; closed suction can be useful in Drain and suction bottle over the fascia, removal 72
the case of clean/contaminated wounds (especially if h later, or if the volume is < 50 m/day
no antibiotics are given). Removal of wound clips after 14 days.

IV. BASIC SURGICAL PROCEDURES ON THE INTESTINES. APPENDECTOMY
IV. Basic surgical 1889 John B. Murphy performed a series of

100 successful appendectomies
procedures on 1902 A successful operation on the British

Crown Prince Edward (VII) before his
coronation ceremony.
the intestines.
1.1. Recapitulation: relevant
Appendectomy anatomy
Motto: If in doubt, take it out. The appendix does not elongate as rapidly as the rest
of the colon, thereby forming a wormlike structure.
Open appendectomy was earlier one of the rst opera- The average length is 10 cm (220) with inner circu-
tions of the young surgeon, but recently it is increasing- lar and outer longitudinal (continuation of the tae-
ly performed with minimal invasive methods (see lat- niae coli) muscle layers. Submucosal lymphoid folli-
er). The intervention is relatively simple in the majority cles enlarge (peak in 1220 years) and then decrease
of the cases; the consecutive steps are built on each other in size, correlating with the incidence of appendici-
and illustrate the classical, well-planned and safe surgical tis. The blood supply is from the appendicular artery
technique. At present the urgent operation is still the only (branch of the ileocolic artery).
safe method of treatment of appendicitis (it must be per- The location of the base is constant, whereas the po-
formed even if there is only a reasonable suspicion). sition of the tip of the appendix varies: 65% retroce-
cal position; 30% at the brim or in the true pelvis;
and 5% extraperitoneal, behind the cecum, ascend-
1. The history of appendectomy ing colon, or distal ileum. The location of the tip of
the appendix determines early signs and symptoms.
1521 Jacopo Berengario da Capri (14601530) Even in a case of surgically veried appendicitis, the
described the appendix as an anatomical Meckel diverticulum should be looked for at the an-
structure timesenteric edge of the ileum, orally 40100 cm
1500s Vidus Vidiuss (Guido Guidi, 15001569) from the appendix. Both can be considered to be
book of anatomy: the term appendix was developmental rudiments; their inammation of-
in general use ten develops simultaneously. Meckel diverticulum
1710 Philippe Verheyen (16481710) coined should be suspected if there is a long-lasting umbili-
the term appendix vermiformis cal discharge in the anamnesis.
1800s Lower abdominal pain as a medical di-
agnosis
1812 A connection was found between peritonitis 1.2. Open appendectomy
and necrotic appendix (John Parkinson).
1824 A connection between periappendicu-
lar inammation and a necrotic appen- An RLQ (right-lower quadrant) incision over the Mc-
dix (Jean Baptiste de Louyer-Villermay) Burney point (2/3 of the distance between the umbili-
1827 A connection between a periappendicular cus and the anterior superior iliac spine). The incision
abscess and the appendix (Franois Melier) was described by Lewis L. McArthur in June 1894, but
1848 Surgical drainage of a periappendicular named after Charles McBurney, who presented a case
abscess (Henry Hancock) in the July 1894 issue of Annals of Surgery.
1867 Several successful drainages of a periap-
pendicular abscess (Willard Parker)
1882 Death of Leon Gambetta, Prime Minis-
ter of France. Autopsy proved a periap-
pendicular abscess
1886 Reginald H. Fitz (pathologist) suggested McBurney pont
(a kldk s a spina
iliaca ant. sup. kztti
that lower abdominal pain is appen- lateralis harmadol pont)
dicitis, and proposed urgent surgery in

the event of signs and symptoms
1887 April 27 George Thomas Morton performed the X
X
rst successful human appendectomy:

removal of a perforated appendix

The sc. tissue and Scarpa fascia are dissected until the
external oblique aponeurosis is identied. This aponeu-
rosis is divided sharply along the direction of its bers.
A muscle-splitting technique is then used to gain ac-

cess to the peritoneum.
The base of the appendix is crushed with a straight

Kocher clamp (after this step, the operation can-
not be regarded as sterile), and then ligated with
a thin absorbable thread (in animals, #40 linen
thread is used).
The peritoneum is lifted up with two forceps or he-

mostats in order to avoid damage to the underlying
viscera. A small incision is made in the peritoneum
and, after entry to the peritoneal cavity (if a purulent
uid sample should be taken for bacteriological di-
agnosis), the appendix is sought out.
Retractors are placed into the peritoneum, and the A seromuscular, purse-string suture is placed around
cecum is identied and partially exteriorized, us- the stump of the appendix, using 3 or 40 thread,
ing a moist gauze pad. The taenia coli is followed to with a round-bodied serosa needle. Care should be
the point where it converges with the other taenia, taken as to the depth of the stitches: if they are too
leading to the base of the appendix. The appendix is deep, the infected bowel content can pass into the
brought into the eld of vision. Gentle manipulation abdominal cavity; if they are too supercial, they
may be required for the blunt dissection of any in- can be torn out.
ammatory adhesions.
Skeletization includes cutting of the mesoappen-
dix and ligation of the appendicular artery (this is
the branch of the ileocolic artery originating from
the superior mesenteric artery; if it is ligated central-
ly, the terminal ileum can be necrotized). The meso-
appendix is cut between Pan hemostats in several
steps (clampingcuttingligating), care being taken
that a tissue collar should be left on the remaining
proximal stump). Generally 30 absorbable thread
is used. Finally, the appendix is completely mobi-
lized step by step.

The appendix is clamped with a Kocher clamp dis- the purse-string suture is then tied. The buried ap-
tal to the crushed line and cut above the base tie, pendix stump is covered with a serosa layer with a
just below the Kocher clamp (the scalpel and the Z stitch, i.e. with a zed-like serosa stitch; thin lin-
appendix should be thrown into the kick bucket). en thread and taper needle are used (this step is not
The stump of the appendix is disinfected with po- obligatory in humans).
vidone-iodine and cauterized (to prevent the later The cecum and appendiceal stump are then placed
secretion of mucus). back into the abdomen. If free perforation is en-
countered, thorough irrigation of the abdomen with
warm saline solution and drainage of any obvious
cavity and well-developed abscesses is required.
The peritoneum is identied, and closed with a
continuous 2 or 30 suture. The inferior oblique
muscles are re-approximated with a gure-of-eight
interrupted absorbable 0 to 30 suture, and the ex-
ternal oblique fascia is closed with an interrupted
20 PG suture. The skin may be closed with staples
or sc. sutures.
In cases of a perforated appendicitis, the skin should
The stump of the appendix is buried (the stump be left open, with delayed primary closure on post-
will be inverted in the lumen of the intestine), and operative day 4 or 5.

V. ANASTOMOSES
V. Anastomoses 2. Causes of anastomosis

insuciency
The origin of the word is late Latin (by Galen) and Greek
(anastomoun = to provide with a mouth; ana + stoma Distal obstruction of the lumen
= mouth, orice). The basic types are side-to-side, end- Perianastomotic hematoma, infection or sepsis
to-end and end-to-side anastomoses. Anastomoses are Hypotension or hypoxia
applied not only in gastrointestinal surgery, but also in Icterus, uremia or diabetes
urology and vascular (etc.) surgery. However, the basis Corticosteroids
of surgical techniques can be best practised in the case
of the small intestine. An important general principle 3. The characteristics of
is that the techniques (e.g. restoration of the anatomy)
serve to restore function (!). a good technique
The precise joining of cut tissues results in primary
wound healing (per primam intentionem, p.p.).
Placing the lowest possible amount of foreign mate-
rial (suture) into the tissues causes the least disrup-
tion of the local circulation.
4. Complications
Suture insuciency
Stricture
5. Anastomosis techniques
Traditional methods
Suturing by hand (there is no evidence that suturing
by hand is better than stapling with staplers)
Staplers or clips (the Hungarian surgeon Aladr Petz
(18881956) invented the gastric stapler and pio-
neered the technique).
New methods
Compression (biodegrading) rings
Tissue adhesives
5.1. Two-layered anastomosis technique

This is the traditional method for anastomoses of the
gastrointestinal tract
1. Healing of the anastomosis An inner continuous catgut (absorbable) suture, with
stitching of all layers
The most important factors inuencing the healing of An outer, seromuscular, interrupted silk (nonabsorb-
the anastomosis are the good blood supply of the tis- able) suture
sues, the lack of tension, and an adequate surgical tech- Serosa apposition and mucosa inversion; the inner
nique, securing the appropriate approximation for the layer has a hemostatic eect (there is no signicant
beginning of collagen formation: bleeding), but the mucosa is strangulated.
Early phase (days 04): There is an acute inamma-
tory response, but no intrinsic cohesion.
Fibroplasia (days 314): Fibroblast proliferation oc-
curs with collagen formation.
Maturation stage (>10 days): This is the period of
collagen remodeling, when the stability and strength
of the anastomosis increase.

V. ANASTOMOSES
5.2. Single-layered technique 7. Closure of enterotomy
This is a newer, more up-to-date technique of gastro-

intestinal anastomosis After laparotomy, the injured bowel segment is
An interrrupted seromuscular suture, with absorbable identied and isolated. The borders are temporar-
(e.g. 3/0 Vicryl) thread. The submucosal layer is strong ily closed (Klammer intestinal clamps) and the de-
and the blood supply is only minimally damaged. fect is enlarged/incised, i.e. converted to a surgical
incision.
A horizontal suture or end-to-end anastomosis is
performed.
Irrigation, handling of bleeding and closure in layers.
5.3. Stapler-made anastomosis
This can be a side-to-side anastomosis with a straight

sewing machine (e.g. GIA = gastrointestinal anasto-
mosis staplers).
It can be an end-to-end anastomosis with a circular
machine (e.g. CEEA = circular end-to-end anasto-
mosis stapler).
The stapler decreases the frequency of radiologically
demonstrated anastomosis insuciency, but the in-
cidence of anastomosis stricture is increased.
6. Surgical techniques of
intestinal anastomoses
Requirements include a supine position, general an-
esthesia, a midline laparotomy and a good exposure;
the aected bowel must be mobilized (freed).
The gastrointestinal tract should always be considered
infected when the intestinal lumen has been closed;
new, sterile instruments and draping are necessary.
The pathological tissue must always be excised with
a normal intact margin (!); the blood supply of the
remaining intestinal tissue is critical.
Relatively equal diameter segments of bowel should
be sewn together. The anastomosis should be ten-
sion-free and leak-proof.
The mesenteric defect is closed (prevention of inter-
nal hernia formation).

V. ANASTOMOSES
8. Surgical unication of bowel

5
segments by end-to-end
anastomosis
The two bowel ends are put in close approximation

and two interrupted, holding sutures are placed. A
continuous running suture is applied to close the
back, and then the front part of the intestinal wall.
After closure of the deeper layer, the serosa (second 6
layer) is closed.
The passage of the anastomosis is checked by exami-
nation with the ngers.
2
8
3
9
4 10

VI. ABDOMINAL DRAINAGE
VI. Abdominal drainage 2.1. Open system
The most frequent causes of surgical diseases of the

small intestine are mechanical causes (obstruction, After insertion of a urinary catheter and a nasogastric
strangulation/adhesion, volvulus, intussusception or fe- tube, local anesthesia is started. A vertical, ~ 2-cm sub-
cal impaction), vascular causes (ischemic colitis, occlu- umbilical incision is made, and the linea alba is divided.
sion/infarct, or arteriovenous malformations), inam- An incision is made in the peritoneum, a peritoneal
mation (diverticulosis/diverticulitis, ulcerative colitis, dialysis catheter is inserted, the free blood or gastric
Crohns disease or appendicitis) or traumas (blunt/pen- content is aspirated, etc.
etrating injuries). Invasive abdominal diagnostic inter- If no blood is seen, 1 of normal saline is infused,
ventions may be needed primarily in these latter cases. a period of 3 min being allowed for equilibration.
The drainage bag is placed on the oor and drainage
proceeds (motto: Gravity is our friend).
1. Historical background A 20-m sample should be sent to the laboratory for
the measurement of red blood cells, white blood cells
of invasive diagnostic and microbiological examination (DPL is positive if
procedures the red cell count is > 100,000 / mm3, the white cell
count is > 500 / mm3, or bile, bacteria or fecal mate-
rial is present).
1950 Four quadrant needle paracentesis. In the event of positive results, DPL is continued un-
1965 Diagnostic peritoneal lavage (DPL the term til surgical exposure (laparotomy), and the demon-
was coined by Root HD et al. Diagnostic peri- stration and treatment of the causes.
toneal lavage. Surgery. 1965; 57:633637). The The peritoneum is closed with a purse-string suture,
sensitivity is 98%, but the specicity is only and the skin and sc. layers are then closed with an
80% (no information is provided on the retro- interrupted suture.
peritoneum).
1990s Laparoscopy became widespread. It has the ad-
vantage of good visualization of the intraab- 2.2. Closed system
dominal organs, whereas it is disadvantageous
that no information is available on the retro-
peritoneum, and the closure is complicated as After insertion of a urinary catheter and nasogas-
compared with punctures. tric tube, local anesthesia is initiated, after which a
catheter is introduced with the aid of a guide wire (a
blind technique; the morbidity of 9%, is mostly due
2. Indication of diagnostic to vessel injury).
The routine is modied in obese patients (special in-
peritoneal lavage dication for closed DPL):
Computer tomography is impossible (weight, diam-
An equivocal clinical examination and diculty in eter limits, poor image, higher radiation).
assessing a patient. Open DPL is contraindicated as the depth of the
Persistent hypotension, despite adequate resuscitation. puncture (peritoneum) can not be judged, and
Multiple injuries, or stab wounds where the perito- hence the complication rate of the closed technique
neum has been breached. is much higher. The half-closed/blind Seldinger or
Lack of alternative diagnostic methods (US or CT). modied Seldinger technique is possible.
3. Therapeutic (chronic) lavage:

peritoneal dialysis
Dialysate is injected into the peritoneal space

through a two-way Tenckho catheter, which re-
mains permanently in place. The peritoneal dialy-
sate, composed mostly of salts and sugar (glucose),

VI. ABDOMINAL DRAINAGE
encourages ultraltration. The peritoneum allows The catheter exits the skin laterally to the midline.
waste and uid to pass from the blood into the dial- A 2030 cm long connecting tube (transfer set) can
ysate, which is pumped out. be fastened to this with a screw thread, with the help
of which the sacks containing the dialysing solution
can be attached. The transfer tube can be closed with
a roller-wheel or with a sterile screw stopper.
4. Therapeutic (postoperative)
rinsing drainage
(see the basics in section IV.10)
The main indication of continuous postoperative

drainage was earlier severe sepsis. Today it is used
mostly for intraabdominal abscesses and inam-
matory processes. It is simple and cheap and can be
life-saving (see details in Csaba Gal: Alapvet Se-
bsztechnika, Medicina, 1998).
Principle: If a cavity is present, it must be open; pri-
mary closure is forbidden.
Problems: Clotting, brin plug and cavity compart-
ment formation resulting from adherence, which in-
creases the risk of bacterial infections.
Main types: Rubber tubes and suction tubes (see sec-
tion IV.10).

VII. BASIC THORACIC SURGICAL PRACTICALS
VII. Basic thoracic Decreased colloidal oncotic pressure nephrotic

syndrome, liver disease
surgical practicals Decreased lymphatic drainage metastatic obstruc-

tion
A thoracic trauma is generally sudden and dramatic;

it plays a role in 25% of the cases of mortality caused 2.2. General principles of treatment
by traumas overall. Two-thirds of the deaths occur af-
ter admission to hospital. It has serious complications: Find the cause
hypoxia, hypovolemia, and respiratory and circulato- Analgetics for pleurisy
ry insuciency are frequent. It can be blunt and non- Thoracocentesis/thoracic tube
penetrating (a trac accident, a direct blow, a fall, or
a deceleration and compression injury) or penetrating
(shot and stabbed wounds, in which primarily the pe- 3. Hemothorax
ripheral lung is aected). The chest wall, pleura, lung
parenchyma, upper airways/mediastinum or heart may Denition: There is blood in the pleural sac, usual-
be injured. If the state of the patient is unstable, tension ly caused by a penetrating trauma. The source of the
pneumothorax, pericardial tamponade and massive he- bleeding can be the alveoli, bronchi or thoracic vessels.
mothorax may be suspected (the route of the trauma The accumulating blood compresses the heart and the
may be an indicator). Complementary examinations are thoracic vessels (one half of the lung may contain ~ 1.5
often needed (echocardiography, bronchoscopy, esoph- of blood). Respiratory disorders can occur, but circula-
agography, esophagoscopy and aortography). Iatrogen- tory disorders are more common. Signs: Tachycardia, a
ic traumas are frequently caused by the introduction of weak pulse and shock-like symptoms. The diagnosis can
nasogastric tubes (endobronchial introduction), chest be established via a chest X-ray (pleura inltration) and
tubes (sc., intraparenchymal or intrassural introduc- diagnostic thoracocentesis.
tion) or central venous catheters.
1. Types of pleural eusion

Transudate (protein content < 3.0 g/m), serous uid
(e.g. malignancies)
Exudate (protein content > 3.0 g/m) caused by in-
ammation
Hemothorax (blood in pleural sac)
Empyema (pus in pleural sac), bropurulent exudate
Chylothorax (lymph)
3.1. Treatment of hemothorax
Fluid, volume and oxygen therapy

Small (300500 m). This may be left alone; it will be
reabsorbed.
Moderate (5001000 m): This requires computer
tomography (CT) and drainage
Large (> 1000 m): CT, drainage and surgery (con-
trol of arterial bleeding) are needed.
2.1. Mechanism/causes of thoracic

eusion formation 4. Pneumothorax (PTX)
Denition: This is a condition in which air or gas is present
Increased hydrostatic pressure in chronic heart failure in the pleural space. This leads to an increased intrapleural
Increased capillary permeability inammation pressure, which causes partial or total collapse of the lung.

4.5. Open PTX

Denition: A hole in the chest wall allows atmospher-
ic air to ow into the pleural space, leading to an in-
creased intrapleural pressure, resulting in partial or
4.1. Etiology of PTX total collapse of the lung. This can be caused by a pen-
etrating injury or be a side-eect of a therapeutic pro-
Spontaneous, primary PTX cedure, e.g. the insertion of a central venous or pulmo-
Blunt chest traumas (motor vehicle accidents and nary artery catheter.
falls)
Penetrating traumas (gunshot and knife injuries),
rib fractures and ail chest
Rib rupture and unstable chest
4.2. Clinical signs of PTX

Tachypnea and tachycardia. Questions: Are there
breathing diculties, or pleurisy? Show its location.
Cyanosis
Diminished breath sounds; hyper-resonance on the
aected side
Neck vein engorgement
Paradoxical movement of the unstable chest; deviat- 4.5.1. Signs of open PTX
ed trachea
Cardiogenic shock
A sucking or hissing sound is audible on inspiration
as the chest wall rises
4.3. Types of PTX Blood, foam and blood clots are coughed up
Shortness of breath / diculty in breathing
Closed or open Pain in the shoulder or chest that increases with
Traumatic or spontaneous breathing
Simple or tension
Primary or secondary
4.5.2. Treatment of open PTX

4.4. Closed PTX
This can occur spontaneously, or it may be a conse-
quence of a blunt trauma or an abrupt pressure rise (a Wound toilette: Larger wounds should be treated rst.
blast or diving). It is particularly frequent in thin, 20 Check for entry and exit wounds (look and feel). An air-
40-year-old male smokers. Most cases resolve after 12 tight, complete cover should be provided at least 5 cm
days. Chest tubes and surgical repair are rarely required beyond the edges of the wound. Three edges of airtight
(< 10%). Treatment: Oxygen, iv. uid, circulatory moni- material (the top edge and two sides) are taped down so
toring and a chest tube if needed. as to create a utter valve eect that allows air to es-

cape from, but not enter the chest cavity (in the USA, 4.7. Signs and symptoms of tension
Petroleum Gauze or Asherman Chest Seal (utter-
valve seal) can be used).
PTX
Early ndings
Chest pain and anxiety
Dyspnea, tachypnea and tachycardia
Hyper-resonance of the chest wall on the affect-
ed side; diminished breath sounds on the affected
side
Late ndings
A decreased level of consciousness
A tracheal deviation toward the contralateral side
Hypotension and cyanosis
Distension of the neck veins (this may not be present
if the hypotension is severe) and increased CVP
5. Treatment of PTX
4.6. Tension PTX 5.1. Basic questions
Iatrogenic or traumatic lesions of the visceral or pari- How much air is present? What is its source?
etal pleura (often associated with rib fracture) is respon- What is the general condition of the patient? What is
sible for one-third of preventable thoracic deaths(!); in the severity of other injuries?
these cases, the rupture of the pleura behaves as a one- Are critical care facilities available?
way valve. Mechanism: A one-way valve allows air to en-
ter the pleural space and prevents the air from escaping
naturally. The increased thoracic pressure leads to col- 5.2. Treatment of simple PTX
lapse of the ipsilateral lung, and pushes the heart, vena
cava and aorta out of position (mediastinum shift), lead- If the size of the PTX is < 20%, bed rest and limited
ing to a poor venous return to the heart, a decreased CO physical activity are called for.
and hypoxia. Etiology: If the size of the PTX is > 20%, thoracocentesis or
barotraumas insertion of a chest tube attached to an underwater
secondary to positive-pressure ventilation (PEEP) seal is necessary.
complication of enteral venous catheter placement,
usually subclavian or internal jugular
conversion of idiopathic, spontaneous, simple PTX
to tension PTX (an occlusive dressing functions as a
one-way valve)
chest compressions during cardiopulmonary resus-
citation
beroptic bronchoscopy with closed-lung biopsy
markedly displaced thoracic spine fractures.
5.3. Treatment of simple PTX with

needle thoracocentesis
Requirements
A 2220 gauge needle, extension tubing, a three-way
stopcock, a 20 to 60 m syringe and supplementary oxy-
gen are required, +/- iv. uids and analgetics.

Technique: see above.
5.4. Emergency needle

decompression
Indication
A diagnosis of tension PTX with any two of the follow-
ing signs:
respiratory distress and cyanosis Option I: Removal of the needle; the plastic cathe-
mental alterations ter stays in place; preparation for placement of the
a nonpalpable radial pulse (hypovolemia) chest tube.
Option II: A plastic or rubber condom is placed on
the end of the needle, which acts as a valve (before
the denite management of the PTX).
Complications
Injury of intercostal vessels and nerves.
PTX (if the procedure is performed in patients without
PTX, the risk rate of lung injury and PTX is 1020%).
Infection.
5.5. Percutaneous thoracocentesis

for the treatment of PTX
Technique
Administration of 100% oxygen; ventilation if neces- Equipments
sary; continuous monitoring; pulse oxymetry if possible. 18 G Braunule, pneumocath (9 F), Seldinger catheter
Location of anatomic landmarks. Surgical chest (616 F), chest tube (1836 F) and water seal/Heimlich
preparation (Betadine and alcohol) and local anes- valve (see later).
thetics (if the patient is awake or if time / the situa-
tion permits).
In cases of trauma, the patients should be supine, 5.6. Chest drain chest tubes
with head tilt; in other patients, a 45o sitting position
is required.
Decompression catheters are placed in the midcla-
vicular line in the 2nd rib interspace. Placement in Indications
the middle third of the clavicle minimizes the risk of Fluid and air should be evacuated from the pleural space
injury to the internal mammary artery. and a negative intrapleural pressure reestablished to reex-
A puncture is made through the skin, 12 cm from pand the lungs, with needle decompression management.
the sternum.
A needle (1416 gauge) or needle catheter (Braunule;
2 inch/5 cm) is used, perpendicular to the skin, just
above the cephalad border of the 3rd rib (the intercos-
tal vessels are largest on the lower edge of the rib).
Once the needle is in the pleural space, the hissing
sound of escaping air is listened for, and the needle
is removed while the catheter is left in place.

Technique The tube is attached to a suction bottle with an un-

There are two main methods are: a) with a trocar, or b) derwater seal, and then xed to the skin with a stitch.
a blunt technique (see above):
Anatomic landmarks are located, and local anes- Complications of chest tube placement
thetic is administered (a 3-cm horizontal incision Mechanical failure of air or uid drainage due to a
is made along the midaxillary line over the 5th or tube obstruction: blood clots or kinks.
6th rib). Sedation; narcotics; preparation of the area Placement in a ssure, infradiaphragmatic or extra-
with Betadine. Draping is optional. pleural.
A 23-cm long transverse incision is made in the Infection of the entry site or pleural uid (a sterile,
skin, followed by the blunt dissection of sc. tissues, aseptic technique is mandatory; the prophylactic use
exactly over the rib. The parietal pleura should be of antibiotics is controversial).
stabbed with the instrument used for preparation Bleeding is rare (if the tube is placed over the top of
(Pan, dissector). the rib to avoid vessels).
The rubber-gloved index nger should be introduced
through the opening (to avoid injuries to the lung,
etc. and free adhesion). 6. Chest drainage system
The proximal end of the chest tube is introduced to
the appropriate length into the pleural cavity. The
tube is introduced along the inner surface of the
chest in the backward and upward direction. Purpose: Negative pressure is created to facilitate re-ex-
During expiration, vapor can be seen in the tube, or pansion of the lungs and to remove air, blood or other
the outow of the air is audible. uids from the pleural space or mediastinal space. The
duration is usually 23 days (24 h after re-expansion), if
the drainage is less than 5070 m/h.
6.1. Indications
Mediastinal, cardiac surgery, chest trauma

Traumatic injury, fractured rib (intrapleural uid,
PTX, hemothorax, pleural eusion)
Management of complications (CVC insertion, lung
biopsy)
6.2. Types
Wet suction (Blau suction or 3-bottle systems). The
air or uid is removed from the pleural space or me-
diastinum. The water-seal acts as one-way valve, al-
lowing air to leave pleural space, but not to return,
maintaining a negative pressure.

fracture leads to chest instability, and the bellows move-

ment of the chest ceases. Signs: Supercial asymmet-
rical and uncoordinated breathing and crepitus of the
ribs. Treatment: Improvement of the respiratory func-
tion, administration of humidied oxygen, chest tubes,
ventilation (PEEP), circulatory support, uid therapy
and analgetics.
Waterless/dry (Heimlich valve) system. A valve is

opened by the pressure of the air or the uid; after
its closure, no backow is possible. During the one-
way function of the soft rubber valve in the plastic
housing, air leaves to the environment. This system
is portable, and can be used for home nursing.
One-piece, three-chamber, disposable plastic systems
(USA: Pleurevac, Atrium/Ocean, or Thoraseal).
8. Cardiac tamponade
Denition: Blood accumulates in the pericardium. As it
has poor compliance, 150200 m of blood can result in
a tamponade, exerting pressure on the heart and limit-
ing the cardiac lling and CO. A decreased CO causes
Autotransfusion: This is a variation of the water-seal
system, with an attached container so that the blood
which drains from the chest can be salvaged for au-
totransfusion.
7. Flail chest
Denition: This involves a multiple (three or more) rup-
ture of the ribs in two or more areas or/and a fracture
of the sternum. Signs: Severe local pain, rapid, super-
cial breathing, paradoxical chest wall movement (some-
times not obvious at the beginning), PTX and lung con-
tusion can be present, which causes severe hypoxia.
There is paradoxical chest wall movement: the serial rib

hypotension. It may occur in patients with either a pen-

etrating or a blunt chest trauma. Signs: Shock, increased
jugular venous BP, pulsus paradoxus (the systolic BP
decreases during inspiration as compared with expira-
tion). In classical cases: Becks triad: 1. distended neck
veins, 2. mued heart sounds, 3. hypotension. Therapy:
Resuscitation and pericardiocentesis.
The technique of pericardiocentesis
Before and during the intervention, the monitoring

of vital signs (ECG) is necessary. The xyphoidal and
subxyphoidal area should be surgically prepared (lo- During aspiration, the epicardium comes close to
cal anesthesia should be applied if time allows). the pericardium and at the same time to the tip of
A #1618 G, 6-inch (15-cm) or longer needle cathe- the needle, and thus the lesion potential can reap-
ter attached to a 20-m syringe is necessary. pear in the ECG. The needle should then be slight-
The skin should be punctured at an angle of ~ 45, 1 ly withdrawn. After completion of the aspiration the
2 cm from the left lower part of the xypho-chondri- syringe should be removed, and a closed three-way
al junction, and the needle should then be carefully stopcock should be attached to the needle catheter
advanced in the direction of the apex of the scapula. and xed.
If the needle goes too deep, lesion potential (neg- Option: In the Seldinger technique, a exible wire
ative QRS) can be seen in the ECG: the needle is advanced through the needle into the pericardial
should be withdrawn until normal ECG is restored. cavity. The needle is removed, a #14-G exible cath-
When the tip of the needle enters a pericardial cav- eter is then introduced through the wire, the wire
ity engorged with blood, as much uid as possible is removed, and nally a three-way stopcock is at-
should be aspirated. tached to the catheter.

VIII. TRACHEOSTOMY
VIII. Tracheostomy Suctioning of uids from deeper airways is possible.

Possibility of the use of a ventillator.
Tracheostomy has been applied for centuries for the 4. The surgical technique of
treatment of upper tracheal obstructions threatening as-
phyxia. In recent decades, it has often been used for the intubation preparation
management of mechanical respiratory insuciency and
functional (dynamic) respiratory failure too. In most of an upper tracheostomy
cases, endotracheal intubation solves the respiratory in-
suciency and tracheostomy is not required. In emer-
gency cases, if the personal and technical conditions of In adults, generally an upper tracheostomy is made, ex-
intubation are lacking, conicotomy/cricothyrotomy is cept when the airway stricture is deeper.
performed. Following a skin incision, the ligamentum After the appropriate positioning, the patient is anesthe-
conicum (lig. crycothyroidum) just underlying the skin tized and intubated, and the skin is scrubbed and draped.
is cut transversally between the thyroid and cricoid carti- Following palpation of the cricoid cartilage, the rst and
lages and endotracheal intubation is performed. Trache- second tracheal cartilages are looked for. Between them,
ostomy is performed if the airway cannot be held open in a short transverse cutaneous incision is made.
any other manner or if the endotracheal intubation (after The white fascia running in the midline (linea medi-
1 week) or conicostoma (after 48 h) must be terminated, ana alba colli) is elevated with dressing forceps and
but the airway must be maintained in an open state. cut with scissors longitudinally.
The longitudinal strap muscles are grasped on both
1. States evoking mechanical sides with dressing forceps and separated with blunt
dissection in the midline. The wound is exposed
respiratory insuciency with retractors by the assistant.
The fascia covering the trachea is lifted by dressing for-
Obstruction: e.g. bilateral recurrent nerve paralysis ceps and divided longitudinally, and the membranous
or a severe laryngeal injury. sheet of the trachea then cut transversally with a scal-
Obturation: a foreign body, blood, secretion, croup or pel between the rst and second tracheal cartilages.
tumor. A mosquito Pan hemostat is placed into the opening.
Constriction: edema, inammation or a scarred stricture. The second tracheal cartilage is elevated by this and
Compression: e.g. struma, lymphoma or other ma- cut through longitudinally in a downward direction.
lignant tumors. In this way a T-shaped opening is created/formed.
An atraumatic stitch is placed into both corners of
2. States evoking functional the cut cartilages. The edges can be opened by the
stitches like casements. In the opening, the endotra-
respiratory failure/insuciency cheal tube becomes visible.
A trachea cannula of appropriate size is selected. The
Diseases of the central nervous system: e.g. injuries, balloon of the cannula must be previously tested.
tumors or inammatory states. The air is sucked from the balloon of the endotra-
Drugs and toxins inuencing the function of the cheal tube with a syringe, and the tube is then with-
central nervous system. drawn over the stoma.
Pathological conditions inuencing the respiratory With the help of the stitches, the opening is ex-
mechanism, such as lesions and diseases of the chest plored; and the tube is carefully placed into the
wall, respiratory muscles, lungs and their innervations. opening and introduced into the trachea. The obtu-
An altered cardiopulmonary state/relations, i.e. de- rator is removed from the tube, and the balloon of
creased oxygenation due to decreased lung perfu- the tube is inated.
sion and ventillation and impaired diusion. The stitches are removed from the cartilage, or
are individually knotted and then tied together
3. Advantages of intubation over and under the tube.
and tracheostomy
The upper airways are open.
The anatomic dead space can be decreased by 50%.
Reduced airway resistance.
Reduced risk of aspiration.

IX. BASICS OF MINIMALLY INVASIVE SURGERY
IX. Basics of minimally ful operations, 1 patient died from a compli-

cation not related to the procedure itself. The
invasive surgery German medical authorities declared that this

was the result of human experimentation.
Mhe was charged with and found guilty of
Motto: The future has already started! homicide.
The goal of video-endoscopic minimally invasive sur- 1987 Phillipe Mouret, in Lyon, is usually credit-
gery is to replace conventional/traditional surgical ed with the rst successful human laparo-
methods, but maintenance of the results and standards scopic cholecystectomy. Perrisat, Dubois and
achievable by open means is essential. Due to the addi- colleagues in communication with Mouret per-
tional benets of magnication, better visualization and formed laparoscopic cholecystectomies shortly
the less invasive approach, greater precision and im- thereafter, and within 10 years, this had become
proved results are possible. This new technical special- the standard technique for cholecystectomy.
ty has developed its own instrumentation, requirements
and a very complex technical background, and thus the
topic is discussed in a separate chapter. Nevertheless, it 2. Present status of minimally
must be borne in mind, that the laparoscopic minimally
invasive technique is based on a rm knowledge of tra-
invasive surgery
ditional surgery. The basis of abdominal (i.e. laparo-
scopic) minimally invasive techniques will be surveyed Minimally invasive procedures routinely applied in
here. Other regions (e.g. the joints and the chest) are the 2006 are diagnostic laparoscopy, laparoscopic chole-
subjects of the relevant specialties. cystectomy and appendectomy, fundoplication, lap-
aroscopic splenectomy and adrenalectomy, laparo-
scopic Hellers myotomy, etc.
1. A brief history of minimally The cutting edge is robotic surgery. The types of
surgical operation (at present) are fundoplication,
invasive surgery cholecystectomy, heart surgery and teleoperation.
The greatest advantage is the elimination of the hu-
1706 Trocar is rst mentioned (trois (3) + carre man factor (trembling hands, eye-hand coordina-
(side), or trois-quarts / troise-quarts in Old tion problems, etc.). The two main systems involve
French). Da Vinci and Zeus manipulators (the former are bet-
ter manipulators, while the latter are smaller instru-
1806 Phillip B. Bozzini (17731809) is often credited ments).
with the use of the rst endoscope. He used a Fetoscopic surgery (laparoscopic in-utero proce-
candle as a light source to examine the rectum dures). More frequent operations (at present) are
and uterus. decompression of the bladder, coagulation of ves-
sel anomalies (radio-ablation in twin pregnancies),
1879 Maximilian Nitze and Josef Leiter invented the cutting of the amnion bands, hydrothorax drainage,
Blasenspiegel (i.e. the cystoscope). and temporal trachea occlusion (in cases of congeni-
tal diaphragm hernia).
1938 A spring-loaded needle was invented by the
Hungarian Jnos Veres (19031979). Although
the Veress needle was originally devised to 3. Advantages of minimal access
create a PTX, the same design has been in-
corporated in the current insuating needles
surgery
for creating a pneumoperitoneum (J. Veress:
Neues instrument zur ausfrung von brust- od- Linking diagnostic and therapeutic procedures
er bauchpunktionen und pneumothoraxbehan- Better cosmesis
dlung. Aus der Inneren Abteilung des Komita- Fewer postoperative complications, hernias / infec-
tsspitals in Kapuvr (Ungarn). Deutsche Med tions
Wochenschr 1938; 64: 14801481). Fewer postoperative adhesions:
fewer hemorrhagic complications
1985 Erich Mhe in Bblingen, West Germany, per- less peritoneal dehydration
formed the rst laparoscopic cholecystectomy lower degree of tissue trauma
(with a galloscope). After nearly 100 success- lower amount of foreign material (sutures)

Shorter postoperative recovery:

less tissue trauma
lower stress in general
less postoperative pain
Patients are able to resume their normal activi-
ties faster (in 6 days on average). The mechanism of
wound healing is identical (!), the recovery depends
on the indication (cause of illness) and the healing
time of incisions/ports, and the latter depends on
the insults of organs and abdominal wall, the stress
caused by general anesthesia, and the healing pro-
cess of the peritoneal damage Conventional laparoscopes have a xed focus. The
Decreased hospital stay (economic advantage) magnication is increased / decreased either by turn-
ing the laparoscope's zooming ring, or by advancing
the laparoscope toward or withdrawing it from the
4. The technical background of targeted area.
Working in a closed environment requires a source
minimally invasive techniques.
of external illumination. Currently, a 150300 W
The laparoscopic tower fan-cooled xenon light source is used to provide col-
or-corrected light for extended periods of time with-
out overheating. The illumination is transmitted to
the laparoscope via a exible beroptic light guide
Main parts (in general): 1. monitor (screen), 2. video (180250 cm long, 0.51.0 cm OD). This illumina-
system (control unit, etc.), 3. light source, 4. insuation is essentially cold: most of the lamp heat is not
tor carbon dioxide cylinder, 5. suction and irriga- transferred to the laparoscope.
tion, 6. electrocautery device, 7. data storage system. A control unit receives the signals from the camera
The endoscope and camera are attached to the units head, converting the optical image into the initial
of the tower via cables. video signal. The camera head attached to the endo-
scope receives the image and converts it to electric
signals.
4.1. Endoscopes
camera attached to the ocular
The ocular is the proximal end of the optical part.

A video camera or conventional camera suitable for
making high-resolution image capture pictures can beroptic
be attached to this part (but the organs can also be light guide
examined by naked eye). The objective is at the dis-
tal end of the optical system.
beroptic objective lense

light source 5 mm
4.2. Diathermy
10 mm
In a bipolar (insulated) system, the tissue is placed
between two electrodes, so that the current passes
from one electrode to the other through the inter-
The objective can be in a 03045- conguration posed tissue. It involves the technology of precision
in relation to the perpendicular cross-section of the coagulation: peripheral vascular and microsurgery.
optical axis. The 0 laparoscope provides a straight- In a monopolar (grounded) system, the ground pad,
forward view, and the 30 laparoscope a forward with a surface area of ~ 50 cm2, is placed over mus-
oblique view. The amount of light forwarded to the cular tissue, and coated with a conductive gel to en-
ocular is the highest in 0 objectives. hance conductance.

4.3. Suction and irrigation Neurohormonal system

The increased intraabdominal pressure stimulates
the secretion of the renin-angiotensin and renin-al-
The rapid removal of abdominal uid is mandatory. dosterone-angiotensin systems which causes vaso-
The irrigation and suction functions can not be sep- constriction.
arated. Central unit: An electric pump with contin-
uous 180 mmHg positive pressure and 500 mmHg Respiratory eects
negative pressure. Fluids: Warm isotonic solutions The increased intraabdominal pressure increases
(saline). the intrathoracal pressure, which decreases the lung
compliance.
Compression of the lower lung lobes, caused by the
5. Physiology of laparoscopy. intraabdominal pressure together with the anesthe-
sia-induced diaphragm relaxation leading to a de-
The pneumoperitoneum crease in lung volume while the dead space increases
(the Trendelenburg position enhances these eects).
As a possibility to improve gas exchange PEEP can
In the abdominal cavity, a large dome-like space must be applied.
be created to displace the viscera and enable the sur-
geon to see and move the instruments about. This may Arterial blood gases
be done by instilling gas under pressure (a pneumo- CO in the systemic circulation causes hypercap-
peritoneum is created). This provides a good opera- nia and respiratory acidosis. Insuation increases
tive eld and helps stop venous and capillary bleed- PaCO by 810 mmHg, together with a decrease in
ing. Historically, this was achieved by the insuation pH. Equilibration starts 1520 min after production
of free air (in gynecology), but at present it is carried of the pneumoperitoneum.
out by introducing carbon dioxide from a closed sys-
tem under pressure. Strict control is needed for main- Urinary excretion
tenance of the pneumoperitoneum. The intraabdomi- Piabd < 15 mmHg decreases the kidney perfusion
nal pressure in adults (Piabd) should be < 15 mmHg; and the glomerular ltration rate, which causes ol-
in pediatric surgery < 6 mmHg is proposed. The safety iguria.
system of the insuator prevents Piabd exceeding the Direct pressure on the kidney parenchyma, renal ar-
set limit (e.g. 15 mmHg). teries and veins causes the renal function to decrease
linearly with pressure (no clinical relevance under
Pathological consequences of the pneumoperitoneum 15 mmHg)
Piabd < 1215 mmHg = a disturbance of the venous
circulation prevails. Liver function
Piabd > 1215 mmHg = the cardiac index decreases, The hepatic and portal circulation progressively de-
and the gas exchange declines. crease, while the concentrations of liver enzymes in
Constantly high Piabd = organ injuries. the plasma increase.
Circulation
The venous backow (preload) is decreasing.
5.1. Complications of
CO pneumoperitoneum
HR
MAP
Total peripheral resistance (afterload)
Pulmonary vascular resistance Vessel injury: The most common sites are the epigas-
The hemodynamic changes in the reverse Trendelen- tric vessels, and vessels in the greater omentum. Large
burg position are more pronounced, venous depres- veins and arteries are rarely injured (this is rare, but has
sion can occur in the lower limbs and the risk of a mortality of 50%).
thrombosis increases. The patient should be placed
in the Trendelenburg or the reverse Trendelenburg Organ injuries: Untreated in 24 h small bowel, large bow-
position only if Piabd is stable. el and liver injuries lead to severe septic complications.
Microcirculation Subcutaneous emphysema: This is caused by CO2 un-

Mechanical compression of the mesenteric vessels; der pressure, which dissects tissues. It can be accidental
decreased splanchnic microcirculation. or intentional (extraperitoneal surgery).

Air emboli: The complication rate is < 0.6% (rare, but are large individual dierences in tolerance. A sig-
potentially lethal). Most common: lung emboli; rare: nicant rise will increase the risk of complications
coronary arteries and brain. caused by diusible gases (air embolus and sc. em-
physema).
Prevention of air emboli An anesthesiology-caused increase in Piabd is due
Safe trocar use to an insucient depth of anesthesia/narcosis/mus-
Intraabdominal pressure control with soluble gases cle relaxation.
(CO) A rapid intraabdominal volume load (e.g. suction/
irrigation) or simultaneous use of other gases (e.g.
Diagnosis of air emboli argon coagulation) also causes an increased Piabd.
Trans-esophageal Doppler US (not in routine use in
laparoscopic surgery) Laparoscopic pain
Capnography (!): detection of end-tidal CO, which The character of this pain differs from that of
decreases as a consequence of decreasing CO + in- open laparotomy. In laparotomy (open surgery),
creasing dead space. A parallel decrease in PaO is abdominal pain predominates. Laparoscopic pain
highly suspicious. is a deep visceral pain (this is covered by abdom-
ECG changes are late, mainly during large emboli- inal pain during open surgery). The characteris-
zation (!) tics are pain in the shoulder and in the shoulder-
blade (caused by the pneumoperitoneum-induced
Therapy of air emboli diaphragm tension and CO-induced acidic irri-
Stop insuation; exsuate pneumoperitoneum; tation).
The left Trendelenburg position decreases emboliza- The therapy includes the complete removal of CO,
tion from the right heart to the pulmonary circulation irrigation with warm saline at the end of the proce-
Central venous catheter into the pulmonary artery dure, and the subdiaphragmatic use of local anes-
for gas aspiration thetic solutions (e.g. bupivacaine).
Pneumothorax: The cause of PTX is an elevated Piabd,

which leads to the opening of embryonal peritoneo-
pleural channels (this is spontaneous PTX). It near- 6. Basic instruments for
ly always occurs in cases of diaphragmatic preparations
(classical case: fundoplication).
minimally invasive surgery
Consequences
Increased airway pressure, increased pulmonary re- A Veress needle is currently the device most common-
sistance ly used to gain access to the peritoneal cavity before
PaCO , PaO insuation. This needle has a blunt obturator, which
CO , compensatory HR retracts on contact with solid tissue to reveal a cut-
ting tip. A marker on the hand piece moves upward
Treatment of pneumothorax as the obturator retracts to expose the cutting tip.
PEEP is applied (5 cmHO) to reinate the lungs and Once the peritoneal cavity is entered, gas may be in-
remove CO. stilled through the hollow shaft of the needle. The nee-
NO administration is stopped; FiO is increased; dle is then removed, and a trocar/cannula is inserted
Piabd should be decreased. through the same site. This method of peritoneal ac-
Thoracocentesis is usually not necessary; CO will cess is referred to as the blind or closed technique.
be absorbed in ~ 30 min and PTX will cease.
Important note: Discernment of CO2-induced PTX and

PEEP-induced rupture of alveoli (caused by emphy- withdrawn blunt obturator
sema) is important. In the event of emphysemic rup-
ture, PEEP will aggravate the signs and the PTX can not
be eliminated spontaneously. The therapy is use of a
chest tube (!)
Increased intraabdominal pressure

A surgical increase in Piabd is followed by circu-
sharp tip
latory and respiratory changes (see above), but there

Trocar: This has a sharply pointed shaft, usually with a

three-sided point. A trocar may be used within a can-
nula, a hollow tube, designed to be inserted into a body
cavity. A trocar is, strictly speaking, the cutting obtu-
rator within a cannula. In practice, the term trocar is
7. Laparoscopic cholecystectomy
commonly used by surgeons to describe the whole tro-
car-cannula apparatus. The main advantages are a shorter operating time and
Once the pneumoperitoneum is established, a port shorter hospitalization (the patient can leave the hospital
must be inserted to allow the passage of the laparoscope 12 days following the intervention); less postoperative
and operating instruments into the abdomen. The entire pain; the structure of the abdominal wall remains intact
apparatus is inserted through the abdominal wall into (the risk of postoperative hernia formation is lower); the
the abdominal cavity. The pressure of the gas producing patient can easily resume his/her former life-style, and
the pneumoperitoneum must be higher then the ambi- can do physical work within a week; this intervention
ent atmospheric pressure. In order to prevent gas leak- can be safely performed on elderly patients with a poor
ing from the port sites, the trocar incorporates a valve. cardiorespiratory state (under high epidural anesthe-
This allows the insertion of instruments without the es- sia, if necessary); in cases of obesity or in patients with a
cape of gas. thick abdominal wall, it is an ideal surgical solution.
trocar obturator
cannula port
spiral xing
Hand instrumentation: For minimal access surgery,

special instrumentation is needed for the remote and
closed surgical environment. These instruments have
been designed to oer a full range of surgical functions
(i.e. clamping, grasping, dissecting and cutting and su-
turing). Thus, the tips of laparoscopic instruments re-
ect those found in open surgery. The instruments pivot
about the fulcrum of the access point with the instru-
ment jaws located within the closed environment, the
handle external to it, and the shaft between them part- 8. Laparoscopic appendectomy
ly in and partly out of the patient. Laparoscopic instru-
mentation ranges from 1050 cm in length (most com- The main advantages are a shortened hospital stay (pa-
monly 30 cm), depending on the distance of the target tients can be discharged on the 2nd3rd postoperative
tissue from the point of access. They can be disposable day, and the normal life-style can be resumed ~ 10 days
(single-use, not safe for resterilization) or reusable (on a following the operation); there is minimal wound pain
long-term basis). (minimal need for pain killer medication); wound sup-

puration does not occur (even in cases of advanced pu-

rulent inammation); in obese patients and those with
a thick abdominal wall, it is an ideal surgical interven-
tion.
9. Training in a box-trainer
The goal of the training is to adapt the tradition-

al open techniques to the laparoscopic setting (this
transition is not too simple). Training should begin The precision intracorporal suturing applied in en-
with exercises in a simulator (suturing trainer box) doscopic surgery was developed by Alexis Car-
using inanimate material. This provides an oppor- rel (18731944) and Charles Claude Guthrie (1880
tunity for the operator to become familiar with the 1963) for vascular and microvascular surgery. The
equipment, the instrumentation, and the particulars intracorporal tissue-suturing procedures allow for
of intracorporeal suturing and knot tying. In a box- the reconstruction of ne tissue structures, because
trainer (MAT-trainer) practice should be per- of the higher surgical accuracy. Today, much bet-
formed with the same quality optical-video-moni- ter results can be achieved with this technique than
tor setup as used in the operating room. This creates with conventional surgical interventions.
true and correct eye-hand coordination.
Training can be as simple as transporting beads

from one container to another or threading needles
through xed eyelets. For the exercise, a 30 lapa- Suturing exercises begin with the suturing of a latex
roscope (diameter 5-10 mm and length 15-30 cm) glove that has two rows of dots marked on it. A cut
is used because this ensures an optimal view with a made through it facilitates the acquisition of skill in
wider eld of vision after it is turned to another po- needle handling, precision entrance-exit bites, su-
sition. turing, and the knot-tying sequence. It is particu-
The students practical training starts with eye-hand larly important that a good technique, such as tar-
coordination exercises to pass needles and suture geting entrance and exit points, should be practised
materials through metal rings. early on in training.
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Surgical Techniques

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What are some of the advantages of laparoscopic cholecystectomy?

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Surgical Techniques, 2

Advanced Medical Skills

ADVANCED MEDICAL SKILLS 89

90 ADVANCED MEDICAL SKILLS

I. Laparotomy the tumor). Two other, fatal operations followed:

3. Basic principles determining

ADVANCED MEDICAL SKILLS 91

4. Recapitulation: Anatomy of 5. Principles of healing of

Hospital factors that aect wound healing negatively

the supercial fascia (Campers),

92 ADVANCED MEDICAL SKILLS

1. Midline; 2. supraumbilical (upper midline); 3. in- 1. Kocher

1.1. Characteristics of longitudinal 3

ADVANCED MEDICAL SKILLS 93

3. Transverse incisions may weaken the strength of the wound healing. If

94 ADVANCED MEDICAL SKILLS

III. Laparotomy in has been opened, the incision can be lengthened

2. Middle median laparotomy

ADVANCED MEDICAL SKILLS 95

96 ADVANCED MEDICAL SKILLS

Modied routine in operations on obese patients

ADVANCED MEDICAL SKILLS 97

IV. Basic surgical 1889 John B. Murphy performed a series of

procedures on 1902 A successful operation on the British

dicitis, and proposed urgent surgery in

rst successful human appendectomy:

98 ADVANCED MEDICAL SKILLS

A muscle-splitting technique is then used to gain ac-

The base of the appendix is crushed with a straight

The peritoneum is lifted up with two forceps or he-

ADVANCED MEDICAL SKILLS 99

100 ADVANCED MEDICAL SKILLS

V. Anastomoses 2. Causes of anastomosis

5.1. Two-layered anastomosis technique

ADVANCED MEDICAL SKILLS 101

5.2. Single-layered technique 7. Closure of enterotomy

This is a newer, more up-to-date technique of gastro-

5.3. Stapler-made anastomosis

This can be a side-to-side anastomosis with a straight

102 ADVANCED MEDICAL SKILLS

8. Surgical unication of bowel

The two bowel ends are put in close approximation

ADVANCED MEDICAL SKILLS 103

VI. Abdominal drainage 2.1. Open system

The most frequent causes of surgical diseases of the

3. Therapeutic (chronic) lavage:

Dialysate is injected into the peritoneal space

104 ADVANCED MEDICAL SKILLS

The main indication of continuous postoperative

ADVANCED MEDICAL SKILLS 105

VII. Basic thoracic Decreased colloidal oncotic pressure nephrotic

surgical practicals Decreased lymphatic drainage metastatic obstruc-

A thoracic trauma is generally sudden and dramatic;

1. Types of pleural eusion

3.1. Treatment of hemothorax