Operative surgery

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Contents
Cholecystectomy

Circumcision
Thyroidectomy
Appendicectomy
Tracheostomy

hydrocele repair

Hernia repair
Varicocele repair
Varicose vein repair
Parotidectomy
Mastectomy
Neck dissection
Incision & drainage of abscess
Excision of lipoma

Excision of sebaceous cyst

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Cholecystectomy

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Cholecystectomy
Indications
Cholelithiasis with complications
Biliary colic a/c & c/c cholecystitis,empyema ,mucocele

Cholelithiasis in a
DM ,immunosuppressed
Hemolytic anemia
Young individuals

Carcinoma
Choledochal cyst
Ca head of pancreas in whipples

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 Anaesthesia
GA

Position
Supine trendelenberg position
Pillow under the right lumbar & tilt to the left

Skin preparation:
Prepare the skin from nipple line to mid-thigh, drape to expose the right
upper quadrants

Incision
Kochers right subcostal Incision (muscle cutting incision)
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Other less common incisions

Midline incision
Muscle is not cut
Less healing bld supply

Paramedian incision
Right upper quadrant transverse incision
Heal easier

Mayo robson incision

Combn of medial half of kochers +paramedian incision

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2 methods
Conventional /classic /retrograde(commonly done)
From cystic duct to fundus

Fundus first method

From fundus to cystic duct
Separate GB from liver bed & cover the raw area on liver by thin peritoneum
Injury to CBD & rt hepatic A

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Procedure
Retract rectus abdominis laterally
Open peritoneum
Pack and retract bowel
Identify GB at the tip of 9th costal cartilage
Catch hold of fundus with sponge holding forceps
Identify calots triangle
Ligate cystic A & cystic duct close to the GB
Separate the GB from liver
Drain to prevent Waltmann Walter syndrome
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Complications
Haemorrhage
Necrosis of right quadrant of liver (d/t rt hepatic artery is affected in
ligature)
Injury to CBD
Bile leak walkmann waters syndrome
May mimic MI

Tachycardia
Upper abdominal pain
Lower chest pain
Shock

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Circumcision

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Circumcision
Indications

Religious
Phimosis paraphimosis
Differentiated carcinoma prior to radiotherapy
Cosmetic

Anaesthesia
LA in adults
Ring block with out adrenaline

GA in children

Position of the Patient: Supine

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Steps

2 forceps on either sides of 12 O clock position of foreskin

Dorsal slit in 12 O clock position halfway to glans
From there cut downward & laterally on either side till u reach frenulum (6 O clock)
Tie frenular artery with U stitch cut vessel distal to ligature
Stitch at 12,3,6& 9 o clock positions
Ligate all bleeding points
4 forceps to hold each of stitches
Suture b/w

12 & 3 ,
3& 6,
6 & 9,
9& 12

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3,Extend the incision

2,Dorsal slit
4,Ligatting frenular A

suturing

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Complications
Infection
Bleeding hematoma
Injury to glans
Delayed healing due to tension

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Post op advices
Handle 4 penis
Apply ice cubes
Urinate every 4 hours
Full bladder can compress deep dorsal vein

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Thyroidectomy

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Thyroidectomy
Indication
Cosmetic
Pressure symptoms
Dyspnea dysphagia

Malignancy

Preparation of the patient

Make the patient euthyroid
To prevent thyroid storm/crisis

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 Anaesthesia :
GA

Position
Supine with neck extended with sand bag under shoulder (rose position)

Clean and drape the area

Incision
Kochers collar incision
2 finger breadths above the suprasternal notch from posterior border of one
sternocleidomastoid to another

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 Skin, superficial fascia containing platysma is cut upto investing layer

of deep fascia
Flaps are raised
Upper upto laryngeal prominence
Lower upto suprasternal notch

Investing layer of deep fascia is incised vertically

Retract srap muscles laterally
Cut them at upper 1/3rd (to prevent injury to ansa cervicalis)
If thyroid is too large
Muscles are infiltrated\
Retrosternal extension with impaction
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 Identify the pedicles

1. Superior thyroid pedicle (sup throid A (branch of ECA )& V (drains in to IJV))
2. Middle pedicle (middle thyroid V only (drains in t IJV))
3. Iferior pedicle (inferior thyroid A only (thyrocervical branch of 1st part of
subclavian A))

Ligate middle thyroid vein first

Short vein drains into IJV (large vein) if missed torrential hge ))

Ligate superior throid A & V separately & close to the gland

Separately: If done together AV fistula can occur
Close to the gland : to prevent injury to external laryngeal nerve
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 Ligate inferior thyroid A close to the gland after identifying & safe
guarding recurrent laryngeal nerve
To prevent loss of blood supply to parathyroids
Sup parathyroid : by sup & inf parathyroid A
Inf parathyroid : by inf parathyroid A only
Identification of parathyroid
Yellowish pink (peanut butter appearance) if devascularised become greyish
Sinks in NS
Position
Sup parathgyroid : middle of superior & inferior throid A
Inferior parathyroid : sup parathyroid & sup mediastinum
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 Identification of RLN

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 Transfix & Ligate thyroidima A,sup thyroid V ,4th thyroid v of kocher

Thyroidectomy proper
Total
Subtotal
Neartotal

Wound closure:
Reapproximate strap muscles and platysma
Skin closure with subcuticular stitch
Dressing

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Complications
Complications of anaesthesia
Complications of Sx
Hge
injury to adjacent structures (trachea esophagus )
Injury to RLN,ext LN,Sup LN parathyroid

Postoperative
Early
Hematoma reactionary hge

Late
Recurrence
Hypothyroidism
Tetany
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Appendicectomy

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Appendicectomy
Indications
a/c appendicitis
Recurrent appendicitis
Carcinoid at the tip of appendix

Contraindications
Appendicular mass faecal fistula

Position
Supine

Anaesthesia
GA
Spinal/epidural
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 Preparation

Cleaned with iodine & spirit

Incision

Muscle splitting incision

McBurneys grid iron

Most popular
6-8cm long at McBurneys point perpendicular to spinoumbilical line

Lanz incision

Curved transverse incision cosmetically better

Right paramedian incision

When diagnosis is doubtful

Bikini incision

Very low & verycosmetic

Part of pfannensteil incision rt part

Muscle cutting

Rutherford Morrison incision

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 Layers opened:
skin
two layers of subcutaneous tissue: Camper's, Scampa's..
external oblique aponeurosis running downwards and medially.it is incised in
the direction of the fibres
Internal and transverse abdominal muscles are split
Peritoneum is opened

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 Locate appendix using taenia coli

Surgical procedure
Appendix is gently held at mesoappendix by using Babcock's forceps and
blood vessels in the mesoappendix are divided.These include appendicular
artery, branch of ileocolic artery.Once the appendix is freed upto the base
(caecum), a purse string suture is applied all round appendix, taking bites
from caecum , using 2-0 atraumatic silk.
Appendix is crushed at the base and is held 1cm above the crush. A tight silk
ligature is applied at the crushed site and appendix is cut in between.Stump is
cleaned with spirit.invaginated and purse string is tightened.This is called
burial of the stump (to prevent adhesions of exposed mucosa)
Perfect haemostasis is obtained.
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 Closure
Peritoneum -continous 2-0 catgut/vicryl
Split muscles -sutured together by a few interrupted suteres using chromic
catgut/vicryl
External oblique is sutured with silk
Subcutaneous fat is sutured with vicryl
Skin with interrupted silk .Instead of catgut, 2-0 silk , 2-0 vicryl is being used
more often nowadays.
Corrugated red rubber drain is not kept routinely unless there is gangrenous
appendicitis or a lot of pus in the peritoneal

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 Postoperative

Ryles tube aspn for 2 days

IV fluids
Appropriate Abx
Suture removal 7-10 days

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Complications
Peritonitis
From spread of infection

Wound infection
Intra abdominal abscess
Fecal fistula formation

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Tracheostomy

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 Indication:
Emergency:
choking, stridor
Coma severe barbiturate poisoning
Foreign body

Elective: Coma , tetanus, barbiturate,head injuries, pulmonary insufficiency

Contraindications:
Anaplastic carcinoma thyroid patients presenting with stridor due to infiltration of
growth into trachea.

Anaesthesia: LA
Position
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Procedure:
Incision:

Tranverse curved incision 3-4cm at the level of 2nd tracheal ring.(horizontal)

Vertical in emergency

Dissection: Skin , subcutaneous tissue and deep fascia are incised.Isthmus of thyroid is separated.
Procedure:
A transversed curved cut is made at the level of 2nd tracheal ring, its edge is held by Allis forceps
and a small cuff of cartilage is removed. Cricoid hook can be used to stabilise the trachea (found
more usefull in children).
Ligate anterr jugular vein ,isthmus of thyroid ,thyroidima
A suitable sized tracheostomy is introduced within.
The cuff of tracheostomy tube is inflated by using 2-5ml of air and is held in place by passing a
tape around the neck.
Confirm the tube in the trachea not in the subcutaneous plane.
Confirm air entry into both lungs.
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 Post op Rx

Suction of tracheostomy tube

Regular dressing
Humidification of air
Check for air entry
Inner tube cleaned in 3 hours outer tube in week ly

Post op complication

wound infection
Air leakage
Improper air entry
cricoid stenosis
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Hydrocele repair

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 Indications
Cosmetic
Symptomatic
Very large

Anaesthesia
LA or spinal

Incision
Paramedian incision on the side of hydrocele

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 Structures cut
Skin
Superficial fascia with dartos muscle
External spermatic fascia

Dissect all around

Study the tunica,size of the sac,thickness of the wall
Make a stab incision & drain the fluid

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Procedures
Small sized & thin wall
Plication of the sac }lords plication
Large sac & thick wall
Eversion of sac } jaboulays procedure
Very large hydrocele
Excision & eversion

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 If the sac is small, thin and contains clear fluid, either

Lords plication, i.e. tunica is bunched into a ruff by placing series of multiple
interrupted chromic catgut sutures so as to make the sac form a fibrous tissue which
is relatively avasular and so haematoma will not occur, or
Evacuation and eversion of the sac behind the testis (after eversion, everted sac is
sutured with chromic catgut by continuous sutures) is done.

If the sac is thick, in large hydrocele and chylocele,

subtotal excision of the sac is done (as tunica vaginalis is reflected on to the cord
structures and epididymis posteriorly, total excision of the sac leads to orchidectomy
with division of cord). Often the sac is excised partially and eversion is done, which is
called as Jabouleys operation.

After evacuation, the sac with the testis is placed in a newly created pocket
between the fascial layers of the scrotum (Sharma and Jhawers
technique).
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Jaboulays operation (Eversion of sac)

A vertical incision is made parallel to the median raphe of the scrotum. The incision is
deepened to cut the dartos muscle, the scrotal fascia and the hydrocele sac, lined by the
parietal layer of the tunica albuginea is exposed. The tunica vaginalis sac is separated
from the dartos muscle layer by finger dissection and a space created between the
tunica vaginalis and the dartos. An incision is made over the tunica vaginalis in an
avascular area anteriorly away from the testis, epididymis and cord structures and fluid
drained. The tunica vaginalis incision is then extended and testis delivered out of the
tunica vaginalis sac. The cut margins of the tunica vaginalis sac is everted around the
testis and the cut margin is stitched behind the testis with 1-0 chromic catgut sutures.
Haemostasis is secured and the testis with the everted sac placed back into the scrotal
sac. The dartos muscle is stitched with 1-0 continuous chromic catgut sutures. The skin is
sutured with interrupted monofilament polyamide suture. A coconut bandage is then
applied. For bilateral hydrocele, the opposite hydrocele may be approached either
through the scrotal septum or by a separate incision on the opposite side parallel to the
median raphe.

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 Closure
Drain is kept
Suture scrotal wound

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 Complication

Injury to testis & epididymis

Scrotal hematoma
Recurrence
infection

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Hernia repair

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Hernia repair
Hernioplasty when herniotomy is combined with a reinforced repair
of the posterior inguinal canal with autogenous (patients own tissue)
or heterogenous material such as prolene mesh.
Herniorraphy is somewhat like hernioplasty only that no autogenous
or heterogenous material is used for reinforcement.
Herniotomy is a surgical operation where the hernia sac is removed
without any repair of the inguinal canal.
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 Indications
All hernia require Sx unless they are eldely /unfit for Sx
Due to risk of complications of hernia

Preparation
Treat the predisposing cause
c/c cough constipation BPH

Anaesthesia
General
Spinal
Local } point block field block } anaesthesia of choice
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 Position
Supine

Cleaning & draping the area

Incision
above & parallel to medial to 2/3rd of inguinal ligament

Structures cut

skin
2 layers of superficial fascia
Ligate superficial epigastric & superficialexternal pudendal
External oblique along the direction of fibres directed towards apex of superficial
inguinal ring
Ilioinguinal nerve is thus identified and preserved
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Herniotomy

Alone is sufficient in childrens

Search for sac (pearly white in colour)

Indirect inside the spermatic cord anterolateral to it

Direct outside the cord & posteromedial to it (therefore spermatic cord is not
opened)

Incase of indirect hernia Incise cremasteric fascia & inrenal spermatic fascia
Expose the sac from fundus to neck separate from spermatic cord
Divide the fundus of the sac in the inguinal canal and reduce the contents
by opening it and with fingers
Identify the neck with
Constriction /narrowness
Inferior epigastric A
Presence of extraperitoneal fat

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 Transfix and ligate the neck by needle passing technique through the
tissue to prevent slipping
Excise the redundant sac
Closure of the wound

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Herniorraphy *(repair of posterior wall)

Indication for In children only when there is collagen vascular
disease,severe anemia,severe malnutrition,CRF
bassinis repair
The conjoined muscle of the transversus abdominis and the internal oblique
muscles is sutured to the inguinal ligament by 3-5 interrupted sutures (non
absorbable suture)
Drawbacks
Undue tension to relieve it tanners slide operation (transverse incision on rectus sheath)
Recurrence due to approximation of muscle to a ligament & thick distant bites

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 Modified bassinis repair

Conjoint tendon to inguinal ligament with continuous sutures

shouldice repair
6 layers
1st &2nd } double breasting of fascia transversalis
3rd & 4th } approximate conjoint tendon to inguinal ligament in 2 layers
5th & 6th } double breast external oblique aponeurosis

Spermatic cord is superficial more chance of trauma

Modified shouldice
Only 4 layers
1st &2nd } double breasting of fascia transversalis
3rd } approximate conjoint tendon to inguinal ligament in 1 layer
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 Coopers ligament repair/mc vays repair

inguinal and femoral canal defects
The conjoined tendon is sutured to Coopers ligament from the pubic cubicle laterally

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Hernioplasty
Lichenstein tension free mesh repair
Rives repair
Preperitoneal mesh is kept with out suturing by incising transversalis fascia

GPRVS/giant prosthetic reinforcement of visceral sac/stoppas repair

By pfannensteil incision/midline vertical
Size of mesh
Breadth = distance B/W 2 ASIS -2cm
Length = b/w umbilicus to pubic symphysis

Desaradas technique
Dynamic repair
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 Closure

External oblique is sutured with chromic catgut or silk.

Subcutaneous fat absorbable catgut suture.
Skin with silk.

Post -op

NPO fro 6-8 hours, oral fluids and soft diet later.
Analgesics
Antibiotics
Scrotal support if the dissection is more(complete hernia)
Suture removal after 7-10days.

Post-op complications

Haematoma
Wound infection
Severe peritonitis pubis
nerve entrapment causing pain.
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Varicocele repair

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INDICATIONS FOR SURGERY

A palpable varicocele.
Symptomatic
Pain

Sub fertility.
Jobs like army

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 VARICOCELECTOMYThe most common approaches are

Palomos operation /high approach
suprainguinal extraperitonial

Classical / inguinal (groin)

easier and safer.

Scrotal approach grade 4 varicocele

Anaesthesia
Spinal /LA/GA

Position
Supine
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Classical
Incision
As in inguinal hernia

Dissect out spermatic cord

All the coverings are split open
The vas deferens with its artery 2 veins are separated from the main
mass of varicocele
The affected veins are ligated proximally & distally and 2 inches of
dilated veins are removed
The ends of ligature are tied together to raise the testis up
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Postoperative advice
Avoid strenuous exercise for 2 days after surgery.
Abx,NSAIDs
Apply scrotal support.

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Complications
20% chance of recurrence.
5% chance of hydrocele
Damage to testicular artery.
Infection.
hematoma

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Varicose vein repair

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Varicose vein repair

Trendelenburg operation
Ligation & stripping

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Trendelenburg operation
Indication Sapheno Femoral Valve incompence (trendelengurg test +ve)
Anesthesia :
Spinal

Position:
Supine

Incision:
Oblique incision at the level of saphenous opening ( 4 cm below& lateral to pubic
tubercle) starting from femoral artery pulsation to 5 cm medially
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 Step 1. Skin flaps reflected and Long Saphenous Vein identified in the Superficial fascia
Step 2. All the tributaries of long saphenous vein at the SFJ are ligated and divided.
Step 3. Long saphenous vein flush ligated with the femoral vein
Step 4. Upper 10 cm Long saphenous vein excised
The conventional way of removing the saphenous vein is with a Babcock stripper. This consists of a flexible wire which is
passed down the long saphenous vein. The end is identified in the upper third of the calf and a 2-mm incision is made to
retrieve the stripper. An olive about 8 mm in diameter is attached to the upper end and the saphenous vein is removed by
firm traction on the wire in the calf.

Step 5. Haemostasis achieved and skin closed & Elastocrepe bandage applied.
Steps 2, 3 and 4 form the components of Trendelenburg Surgery

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 Complications
Haematoma
Recurrence (up to 20%)
Saphenous nerve injury - loss of sensation medial thigh

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Parotidectomy

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 1. Superficial parotidectomy:
It is the removal of superficial lobe of the parotid (superficial to facial nerve.).
It is done in case of benign diseases of superficial lobe of the parotid.

2. Total conservative parotidectomy:

It is done in benign diseases of parotid involving either only deep lobe or both
superficial and deep lobes. Here both lobes are removed with preservation of
facial nerve.

3. Radical parotidectomy:
Both lobes of parotid are removed along with facial nerve, fat,fascia, muscles,
and lymph nodes. It is done in case of carcinoma parotid. Later facial nerve
reconstruction is done using hypoglossal or
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Superficial parotidectomy
Indication
Recurrent parotitis
Benign tumours

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Superficial Parotidectomy
Oral endotracheal
Anaesthesia : GA
Position
Head is extended by elevating the shoulders
Head rotated to the contralateral side

Draping the head separately incorporating the endotracheal tube

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Skin incision
Lazy S Incision
From the level of tragus of the
ear ( along the crease), winding
around the lobule towards the
mastoid and curving down
anteriorly 2 inches along the
anterior border of SCM to upper
Cervical crease.

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Lazy s incision

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Allis clamps on subcutaneous tissues provide traction of the

flaps
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 The incision is carried through skin and subcutaneous tissue,

Developing the plane between the cartilaginous external canal and
the posterior aspect of the gland

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Identify cartilaginous pointer

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Anatomical landmarks For identification of Facial

N Trunk
1.

The cartilaginous external auditory meatus forms a pointer at its anterior, inferior border
indicating the direction of the nerve trunk. (Tragal Pointer)

2.

Just deep to the cartilaginous pointer is a bony landmark formed by the curve of the bony
external meatus & its abutment with the mastoid process. This forms a palpable groove
(Tympanomastoid Suture) leading directly to the stylomastoid foramen.

3.

The anterior, superior aspect of the posterior belly of the digastric

4.

Styloid process itself can be palpated superficial to the stylomastoid foramen & just superior
to it. Nerve is always lateral to this plane & passes obliquely across the styloid process.

5.

Retrograde Dissection

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The mastoid process palpated to identify the

origin of the sternocleidomastoid
The sternomastoid muscle is identified and
its anterior border exposed as the tail of the
gland is dissected and reflected away from
the muscle

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Identify anterior border of posterior belly of

digastric
Continues to dissect in this plane, incising
attachments to the mastoid, until the
posterior belly of the digastric muscle is
visualized below the digastric groove

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 When the volar aspect of the fifth finger is placed deeply on the
junction of cartilaginous and bony external auditory canal and
wedged against the bone cephalad, the main trunk will be found
below the inferior border of the finger, a few millimeters above the
exposed superior border of the posterior belly of the digastric muscle
as it enters its groove in the mastoid bone

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Identify facial nerve trunk

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 Once the facial nerve trunk has been identified the superficial lobe
exteriorised by opening up the plane in which the branches of the
facial nerve run between the two lobes by blunt dissection
Small hemostat in the plane superficial to N, elevating the hemostat
laterally, gently spreading the tips, and then incising the tissue
between the tips with direct visualization of the N
Good traction on the reflected parotid

Clamp is used to elevate and incise the overlying tissue in layers

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After the lateral portion of the gland has been

removed, all nerve branches should be exposed.

If a clean dissection has been performed, at least a portion of

the masseter muscle should be in view
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The Stensen duct is

transected and ligated
anteriorly

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Suture & keep drain

drain
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Conservative parotidectomy

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Complications
Intra-operative complications

Transection of facial nerve

Rupture of capsule
Haemorrhage

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Post Operative Complications

Early

Late

Facial N Paralysis
Hemorrhage
Hematoma
Infection
Skin Flap Necrosis
Cosmetic Deformity
Trismus
Parotid Fistula

Hypoaesthsia
Soft Tissue Defect
Hypertrophic Scar
Freys Syndrome
Crocodile tear
syndromr

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Intra Op Transection OF Facial N

Immediate nerve repair
Segments fully mobilized
Brought together without tension

Two ends should be sutured together

With an 8-0 nylon suture
As an alternative to sutures, fibrin tissue adhesive can be used.

If the nerve length is inadequate, a nerve graft of the greater

auricular

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Mastectomy

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Operative procedures-Mastectomy
1. Simple mastectomy.
2. Modified radical mastectomy.
3. Breast conserving surgery.

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Total or simple mastectomy:

Removal of the entire breast tissue,

No dissection of lymph nodes or removal of muscle.

Sometimes adjacent lymph nodes are removed along

with the breast tissue.

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Which procedure is best ?

Loco-Regional therapy include:
a. Surgery

b. Radiotherapy

Systemic therapy:
a. Chemotherapy
b. Hormonal therapy

c.

Monoclonal antibodies.

However surgery is important to get rid of gross cancer

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Pre-operative management
Triple assessment.
Metastatic workup.

Routine blood investigations.

Pre-anesthetic evaluation.

Control of medical conditions like diabetes and hypertension.

Counseling and written informed consent.

Parts preparation- neck to mid thigh including pelvic region, axilla

and arm.
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Operative procedure
Anesthesia
General anesthesia.

Position
The patient is placed in supine position with the arm
abducted < 90 degree.
Sandbag or folded sheet is placed under the thorax and

shoulder of affected side.

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Operative procedures- Simple Mastectomy

Indications:

Stage I and stage IIa carcinoma

Large cancers that persist after adjuvant therapy

Multifocal or multicentric CIS.

Incision:

Horizontal elliptical incision is marked so as to include the entire

areolar complex.

Should be 1-2cm away from the tumor margins.

Skin sparing incision- if breast reconstruction is planned

Two skin edges should be of equivalent length

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Simple Mastectomy-procedure
Skin incision is deepened with electrocautery.
A plane between breast fat and the

subcutaneous fat, seen as white fibrous

plane.

Dissection is carried in this plane and

flaps are raised inferiorly and superiorly.
Ideally thickness of the flap should be 7-

10mm.

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Simple Mastectomy-procedure
Extent of dissection:
Superiorly till clavicle,
Laterally till P.major lateral border
Medially to the sternal border, and
Inferiorly till infra-mammary fold

Breast tissue along with the pectoral fascia

(controversial) is dissected from the P.major.
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Simple Mastectomy-procedure
Usually started superiorly and the proceeded clock-wise ending
in the axillary region.
Care must be taken to ligate perforating branches of lateral
thoracic and anterior intercostal vessels.
Lateral branches of the medial pectoral neurovascular bundle is
carefully dissected while removing axillary tail.
Wound irrigated with sterile water to crenate (shrivel or shrink)
cancerous cells.
Subcutaneous tissue is closed using 00 absorbable interrupted
sutures.

Skin closed using 00 non-absorbable mattress sutures or using

staples.
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Modified Radical Mastectomy (MRM):

Removal of breast tissue and axillary lymph nodes.

No removal of pectoral muscle.

3 modifications:
a.

Pateys

b.

Scanlons.

c.

Auchincloss.

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Modified radical Mastectomy-procedure

1. Pateys procedure:

The P.minor is removed for better visualization and easy

dissection of level III lymph nodes.

2. Scanlons procedure:

P.minor is retracted to expose level III nodes and dissected out.

3. Auchincloss procedure:

Level I and II lymph nodes are cleared, level III nodes are left
behind.
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Operative procedures- Modified radical

Mastectomy

Indications:

Early breast cancer (most commonly done)

LABC

Residual large cancers that persist after adjuvant therapy

Multifocal or multicentric disease.

Incision:

Oblique elliptical incision angled towards axilla.

Should include the entire areolar complex and previous scars, if present.

Should be 1-2cm away from the tumor margins.

Two skin edges should be of equivalent length

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Modified radical Mastectomy-procedure

Procedure till approaching axilla is
same as simple mastectomy.

Extent of dissection:
Superiorly till clavicle,
Laterally till anterior margin of
latissimus dorsi.
Medially to the sternal border, and
Inferiorly till the costal margin near the
insertion of the rectus sheath.
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Modified radical Mastectomy-procedure

The specimen is retracted upwards and laterally to expose
P.minor.

The dissection is continued to axillary lymph node

clearance.
Care must be taken not to injure medial pectoral nerve
and vessels.
The axillary investing fascia is incised to expose the
axillary group of lymph nodes.
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Modified radical Mastectomy-procedure

The inter-pectoral (Rotter) group of lymph nodes are removed.

Then dissection can be done either from medial to lateral or viseversa.

The loose lateral areolar tissue in axillary space is dissected to

expose the axillary vein.

The investing layer of axillary vessels is cut, the tributaries are

transfixed and cut.

Dissection is carried out laterally including lateral grp (level I) of

lymph nodes.
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Modified radical Mastectomy-procedure

Thoracodorsal neurovascular bundle lies over the lat.dorsi, with

nerve more laterally placed, subscapular (level I) nodes are removed.

The level II lymph nodes between superior trunk of

intercostobranchial bundle and axillary vein are removed.

The central grp of lymph nodes are removed carefully separating

from axillary vein and its tributaries.

While dissecting medially, long thoracic nerve is encountered, which

lies anterior to the subscapular muscle. The dissection carried out
anterior and medial to long thoracic nerve and the specimen
delivered.
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Modified radical Mastectomy-procedure

Care must be taken while dissecting in axillary area to
preserve,

Medial and lateral pectoral nerve.

Long thoracic vessels and nerve
Nerve to latissimus dorsi.
Axillary vein.

Wound irrigated with sterile water to shrink/crenate

cancerous cells.
2 drains, 1 below and other above P.major are secured.
Subcutaneous tissue is closed using 00 absorbable
interrupted sutures.
Skin closed using 00 non-absorbable mattress sutures or
using staples.
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Post-operative care
Wound examined on post-op day 3.
Drain can be removed when it is < 30ml.

Any collection is to be aspirated under aseptic precautions.

Staples can be removed after 10days.

Arm movements started in the 1st week..

Active shoulder and upper limb exercises are started from 2

weeks

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Types of mastectomy
3. Halsteds Radical Mastectomy:

Most extensive type.

Breast tissue, axillary lymph nodes and pectoral muscles are removed.

Disadvantages:

Bad scars and unacceptable deformity.

Reduced range of mobility of shoulder

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Types of mastectomy
5. Skin sparing mastectomy:

4. Subcutaneous mastectomy:

Total/simple mastectomy or

Simple mastectomy sparing nipple.

modified radical mastectomy

Rarely done, as a large amount of

with preservation of as much

breast tissue is left in situ.

as breast skin as possible

needed for breast
reconstruction.

Local recurrence is
acceptable, 0-3%.
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Types of mastectomy
6. Breast conserving surgery:
Wide local excision/Lumpectomy
Quadrantectomy.

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Breast conserving surgery

Indications:

Method:
Wide local

Stage 0 (CIS), Stage I,

excision/Lumpectomy or
Quadrantectomy +

Stage IIa breast

carcinoma.

axillary lymph node

Single lesion.

clearance +

Clinically downstaged

radiotherapy.

LABC (controversial)
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Types of mastectomy
7. Extended radical

8. Toilet mastectomy:

mastectomy:

Radical mastectomy +

Done in fungating or
ulcerative growths.

enbloc resection of

internal mammary lymph

nodes + supraclavicular

Palliative simple
mastectomy.

lymph nodes.

Obsolete.
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Which procedure is suitable for the given patient ?

Age

Menstrual status.

Size of the tumor

Size of the breast

Axillary lymph node status.

Availability of

Stage of the malignancy

radiotherapy.

Biologic aggressiveness of the

tumor

Receptor status of the tumor.

Multicentricity or multifocality

Patients choice.
Prophylactic/therapeutic/
palliative.

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Which procedure is best ?

When the tumor size is 1cm, becomes systemic.
No single method is considered better in terms of
disease free survival or mortality.

Suitable local therapy + systemic therapy is the most

appropriate approach.

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Breast conserving surgery

Contraindications:

Multicentric tumor.

Positive margins after excision.

Size > 4cm (relative).

Advanced stages.

Advantages:
Maintenance of appearance
and function of breast.
Disease free interval is same as
MRM.

No assess to radiation/ poor

Better quality of life and

patient compliance.

C/I for radiation: SLE/ Rheumatoid

psychological advantage.

arthritis/ Scleroderma/ pregnancy/

prior chest radiation.

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Breast conserving surgery-Procedure

Incision-circular/ radial/ subareolar incision near to the tumor,
about 3-4cm.

Excision of the carcinoma tissue with a margin of atlaeast 1cm

of normal breast tissue to get a 2-mm cancer-free margin.
If tumor is situated superficially then excision of that part of skin.
If tumor is deep then tumor is excised till pectoralis major.

Depending on post-surgical defect

Primary closure or
Reshaping of breast tissue isTONY
done.
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Breast conserving surgery-Lumpectomy

After skin incision, subcutaneous tissue is deepened using electric
cautery.
While dissecting the breast tissue, better to use scalpel.
Care must be taken while dissecting to palpate the tumor, so that
entire lesion is excised. Specimen radiography can be done to check
for clear margins.
Hemoclips are applied along the margins of the cavity.
Wound closed in 2 layers:
Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.
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Skin with subcuticular 3-0 absorbable sutures.

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Breast conserving surgery-Procedure

Quadrantectomy:
Usually done for lesion in the upper outer and inner lower

quadrants.
Radial incision is taken.

Entire breast tissue in that quadrant is excised till pectoral fascia.

Wound closed in multiple layers:
Breast tissue with interrupted 3-0 absorbable suture.
Subcutaneous tissue with interrupted inverted 3-0 absorbable suture.
Skin with subcuticular 3-0 absorbable suture.
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Breast conserving surgery

Quadrantectomy v/s Lumpectomy.
Lumpectomy has more local recurrence risk.

Lumpectomy has better cosmetic outcome.

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Breast conserving surgery

After BCS, radiotherapy is essential, otherwise the
local recurrence rate is unacceptably high
Without radiotherapy, the local recurrence can be as
high as 40%

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Neck dissection

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Neck dissection
Medina classification (1989)
Radical neck dissection
Extended radical neck dissection
Modified radical neck dissection

Type I (XI preserved)

Type II (XI, IJV preserved)
Type III (XI, IJV, and SCM preserved)(Known as Functional neck dissection (Bocca))

Selective neck dissection

Supraomohyoid neck dissection

Posterolateral neck dissection
Lateral neck dissection
Anterior neck dissection

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Radical neck Dissection:

Removes
Removing all lymphatic tissues in
regions I - V
Spinal Acessory Nerve
Internal Jugular vein
Sternocleidomastoid muscle
Submandibular Salivary gland
Tail of parotid
Omohyoid muscle

Preserves

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Suboccipital
Retropharyngeal
Periparotid
Perifacial
Paratracheal nodes

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Indications

Radical Neck Dissection

1. Multiple clinically obvious cervical lymph node metastasis particularly of
posterior triangle and closely related to SAN
2. Large metastatic tumor mass or multiple matted in upper part of the neck

Tumor should not be dissected to preserve Structures

Contraindications
1. untreatable primary lesion (fixed)
2. Involvement of internal / common carotid artery
3. Presence of distant metastasis.
4. Poor anaesthetic risk patient.

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Modified radical neck dissection:

Excision of all lymph nodes removed with RND (Nodal groups I-V)
with preservation of one or more non-lymphatic structures, SAN, SCM and/or
IJV
Subtype I: Preserve SAN
Subtype II: Preserve SAN & IJV
Subtype III: preserve SAN, IJV and SCM
Known as Functional neck dissection (Bocca)

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Type l MRND

Indications
Clinically obvious lymph node metastases
SAN not involved by tumor
Intraoperative decision

(XI preserved)

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Type ll MRND
Indications
Rarely planned
Intraoperative tumor found adherent to the SCM, but not IJV
& SAN

Preserve SAN
&
IJV

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Type lll MRND/ Functional neck dissection

Neck dissection of choice for N0 neck

For treatment of N0 neck nodes

Indicated for N1 mobile nodes and not greater than 2.5 3.0
cm
Contra-indicated in the presence of node fixation
Result is difficult to interpret because of the use of radiation
therap

preserve SAN, IJV and SCM

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Extended Neck Dissection

Definition
Any previous dissection which includes removal of one or more
additional lymph node groups and/or non-lymphatic structures.
Usually performed with N+ necks in MRND or RND when
metastases invade structures usually preserved

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Selective Neck dissection:

Also known as an elective neck dissection
Need for post-op RT
Any type of cervical lymphadenectomy with preservation of one or more
lymph node groups
Four subtype:

Supraomohyoid neck dissection

Posterolateral neck dissection
Lateral neck dissection
Anterior neck dissection

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Indications
Selective/elective neck dissection:
For treatment of N0 neck nodes
For N+ nodes when combined with radiotherapy

Adjuvant radiotherapy for patient with 2 4 positive

nodes or extra-capsular spread
Upgrade intra-operatively following positive frozen section

Supraomohyoid neck dissection

Most commonly performed SND
Definition
En bloc removal of cervical lymph node groups I-III
Posterior limit is the cervical plexus and posterior border of the SCM
Inferior limit is the omohyoid muscle overlying the IJV

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Supraomohyoid neck dissection

Indications
Oral cavity carcinoma with N0 neck
Boundaries Vermillion border of lips to junction of hard and
soft palate, circumvallate papillae
Subsites - Lips, buccal mucosa, upper and lower alveolar ridges,
retromolar trigone, hard palate, and anterior 2/3s of the tongue and
FOM

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Lateral Type
En bloc removal of the jugular lymph nodes including Levels II-IV.
Indications
N0 Neck in carcinomas of
Oropharynx
Hypopharynx
Supraglottis
Glottic Larynx

Posterolateral type
En bloc excision of lymph bearing tissues in Levels II-IV and additional
node groups suboccipital and postauricular.
Indications
Cutaneous malignancies
Melanoma
Squamous cell carcinoma
Merkel cell carcinoma

Soft tissue sarcomas of the scalp and neck

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Anterior neck dissection

En bloc removal of lymph structures in Level VI

Perithyroidal nodes
Pretracheal nodes
Precricoid nodes (Delphian)
Paratracheal nodes along recurrent nerves

Limits of the dissection are the hyoid bone, suprasternal notch and carotid
sheaths
Indications

Selected cases of thyroid carcinoma

Parathyroid carcinoma
Subglottic carcinoma
Laryngeal carcinoma with subglottic extension
CA of the cervical esophagus
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Y Incision

3 point
intersectionflap
necrosis

McFee Incision

H Incision

J Incision

COMPLICATIONS
Air embolus
Pneumothorax
Chyle leak & Chylus fistula
Wry Neck (Torticollis Coli)
Shoulder dysfunction
Cerebral oedema

Incision and drainage of abscess

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 Indications
1.

Abscess on the skin which is palpable

Contraindications
1.Extremely large abscesses which require extensive incision, debridement, or
irrigation (best done in OR)
2. Deep abscesses in very sensitive areas (supralevator, ischiorectal,
perirectal) which require a general anesthetic to obtain proper exposure
3. Palmar space abscesses, or abscesses in the deep plantar spaces
4. Abscesses in the nasolabial folds (may drain to sphenoid sinus, causing a
septic phlebitis)
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 Preprocedure education

1.
Obtain informed consent
2.
Inform the patient of potential severe complications and their treatment
3.
Explain the steps of the procedure, including the not insignificant pain associated
with anesthetic infiltration
4.
Explain necessity for follow-up, including packing change or removal

Procedure

1.
Use universal precautions
2.
Cleanse site over abscess with skin prep
3.
Drape to create a sterile field
4.
Infiltrate local anesthetic, allow 2-3 minutes for anesthetic to take effect
5.
Incise widely over abscess cutting through the skin into the abscess cavity. Follow
skin fold lines whenever able while making the incision

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 6.Allow the pus to drain, using the gauzes to soak up drainage and
blood. Use culture swab to take culture of abscess contents, swabbing
inside the abscess cavity
7.Use the hemostat to gently explore the abscess cavity to break up
any loculations within the abscess
8. Using the packing strip, pack the abscess cavity
9. Place gauze dressing over wound, and tape in place

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Excision of lipoma

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 Indication

Large size (cosmesis/patients wish)

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

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 Surgical procedures

Incision: A linear incision over the summit of the swelling is placed and flaps raised
on both sides of the incision.
Layers opened: skin and some part of the subcutaneous tissue till the capsule of the
swelling is encountered.
Dissection : using an artery forceps or a moquito forceps( if a small swelling) , a plane
is created between the raised flaps and the capsule of the swelling.Pressure is given
at the base of the swelling to deliver out of lipoma.A small vessel may be
encountered as the base is being dissected that should be identified and cauterised
or ligated.The specimen should be sent for hisptopathological evaluation.

Closure

The cavity left after the excision can be closed by few interrupted vicryl sutures to
close the subcutaneous layer. The excess skin is removed. The skin is closed with 2.0
ethilon vertical mattress suture. Sometimes a drain may have to be kept to drain the
cavity.Remove suture after 7-10days.
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Excision of sebaceous cyst

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 Indication : Infection , cosmesis

Surgical procedure:

Elliptical incision around the summit of the swelling encircling the punctum.
Layers opened:
Incision should be superficial. Care should be taken not to cut open the cyst wall.
The principle is to completely excise the cyst with its wall and the overlying punctum and a bit of
the surrounding skin around the punctum.
Dissection
A plane is created between the skin and the cyst, carefully, preventing opening of the cyst wall.
An Allis forceps may be applied to the punctum and the elliptical skin to get a traction. Flaps need
to be raised gradually on either sides of the incision and then deliver the cyst in toto.(huh?)
If the cyst wall opens up, the sebum is removed completely and an effort to remove all the cyst
wall in piece meal is made.
Closure: Single layer closure of the skin. suture removed after 7-10 days.

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Thanks to

Our Teachers
Noufal T B
Wajidha P K
Tintu Rose Thomas
Swathikrishna Babu
Vivek Krishna M S
Tariq Navas
Thomas John
Thouseef Muhammed K M
Umbing Mudang
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