SURGICAL SPECIALTIES
(Endoscopy and Robotic-Assisted Surgery)
Dr. Jonathan M. Paghubasan
ENDOSCOPY
Access Portal into the Body
• Natural orifice or functional stoma
• Puncture or incision
Knowledge and Skill for a Safe Endoscopic
Environment
• Attributes of the Endoscopic Team- The
attributes of the team members complement
each other within their own scope of practice.
Together, they provide the knowledge and
skill necessary for the safe and effective
performance of an endoscopic procedure.
• Attributes of the Surgeon- surgeon must
have an expert knowledge of anatomy and
physiology
Hazards of Endoscopy
• Perforation
• Bleeding
• Hypothermia
• Preperitoneal insufflation
• Gas embolism
• Incidental iatrogenic injury- Improperly
grounded electrical equipment, Unsuspected
current leaks
Considerations for Patient Safety
• The patient should be monitored for signs
and symptoms of reaction to drugs.
• A topical agent is frequently applied to nasal
or oral and pharyngeal mucosa before
introduction of an endoscope into the
tracheobronchial tree or gastrointestinal tract
• The teeth, gums, and lips are protected if the
endoscope is introduced through the mouth.
Dentures are removed
• Hydrogen and methane gases are normally
present in the colon. These gases are
flushed out with carbon dioxide before laser
surgery or electrosurgery through the
colonoscope to avoid the possibility of
explosion within the colon.
• Power sources and lights should be tested
before each use and after cleaning
• The heat generated from the projection lamp
of a fiberoptic illuminator is dissipated.
• Endoscopes should be smooth, with no nicks
on the surface
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• Extreme care should be taken to observe
patients after e scopic procedures for effects
of respiratory or circulatory system distress
caused by gas absorption, trauma, or
medication.
GENERAL SURGERY
• Special Considerations for General Surgery
• A central core of knowledge and skills
common to all surgical specialties (e.g.,
anatomy, physiology, metabolism,
pathology, immunology, wound healing,
shock and resuscitation, neoplasia, and
nutrition)
• The diagnosis and preoperative,
intraoperative, and p tive care of patients with
diseases of the alimentary tract; the
abdomen and its contents; breast; head and
neck; endocrine system; and vascular
system (excluding intracranial vessels, the
heart, and vessels intrinsic and immediately
adjacent thereto)
• Responsibility for the comprehensive
management of trauma and critically ill
patients with underlying surgical conditions
BREAST PROCEDURES
• Incision and Drainage- Surgical opening of
an inflamed and suppurative area is most
often carried out because of infections in the
lactating breast.
• Breast Biopsy- Fine-needle aspiration,
Core biopsy, Stereotactic breast biopsy,
Incisional biopsy, Excisional biopsy, Sentinel
node biopsy, J-wire or needle localization in
radiology department, Fiberoptic ductoscopy
• Lumpectomy- a partial mastectomy,
consists of removal of the entire tumor mass
along with at least 1 to 2 cm of surrounding
nondiseased tissue.
• Segmental Mastectomy- a wedge or
quadrant ( tomy) of breast tissue is removed;
this wedge includes the tumor mass and the
lobe in which it is growing.
• Simple Mastectomy- the entire breast is
removed without lymph node dissection.
• Modified Radical Mastectomy- usually
performed for i trating ductal and localized
small malignant lesions. The term modified
encompasses various techniques, but all
include removal of the entire breast (total
 mastectomy). In addition, all axillary lymph
nodes are resected.
• Radical Mastectomy- the entire involved
breast is removed along with the axillary
lymph nodes, the pectoral muscles, and all
adjacent tissues.
• Extended Radical Mastectomy- The
involved breast is removed en bloc along
with the underlying pectoral muscles, axillary
contents, and upper internal mammary
(mediastinal) lymph node chain. This
procedure is more difficult than a classic
radical mastectomy.
• Cholecystoduodenostomy and
cholecystojejunostomy are bypass
procedures to avoid further obstructive
jaundice, but they do not solve the problem
• Choledochoduodenostomy and
choledochojejunostomy are side-to-side
anastomoses between the duodenum or
jejunum and the common duct.

LIVER PROCEDURES
• Liver Needle Biopsy- percutaneous needle
biopsy may help establish a diagnosis of liver
disease
• Drainage of Subphrenic and Subhepatic
Abscesses- these abscesses are treated by
incision and drainage. A catheter may be
introduced into the abscess cavity, which has
been localized on a CT scan.
• Intraoperative Hepatic Ultrasound- used
to identify anatomic sutures or liver densities
associated with a primary tumor or
metastasis.
• Hepatic Resection- Lobectomy or
segmental resection is indicated for cysts,
benign or malignant tumors, or severe
penetrating or blunt trauma.
• Portosystemic Shunts- A portosystemic
shunt is a vascular anastomosis between the
portal and systemic venous systems.

SPLENIC PROCEDURES
• Splenectomy- The most common reason
for removal of the spleen is hypersplenism—
overactivity that causes a reduction in the
circulating quantity of red cells, white cells,
platelets, or a combination of them.
• Splenorrhaphy- The spleen can then be
sutured or stapled along the edge of a partial
splenectomy.

PANCREATIC PROCEDURES
ABDOMINAL PROCEDURES
• Pancreaticojejunostomy- These methods
• Biliary Tract Procedures involve a tomosing a loop of the jejunum
• Cholecystectomy- removal of the (Roux-en-Y loop) to the pancreatic duct.
gallbladder. (Open Abdominal Hemorrhage and leakage of bile are
Cholecystectomy., Laparoscopic complications to be avoided.
Cholecystectomy.) • Pancreaticoduodenectomy (Whipple
• Common Bile Duct Exploration- Procedure)- Pancreaticoduodenectomy is
Concomitant exploration of the common an extensive procedure performed on
duct. Intraoperative Cholangiograms., patients with carcinoma of the head of the
Ultrasonography, Choledochoscopy, pancreas or the ampulla of Vater. l include
Cholelithotripsy, Choledochostomy and anastomosis of the pancreatic duct, c mon
Choledochotomy bile duct, stomach, and jejunum.
• Cholecystoduodenostomy and • Pancreatectomy- performed to resect a
Cholecystojejunostomy- Through benign tumor or for chronic pancreatitis. The
anastomosis, these procedures establish c distal tail is resected to the head of the
ity between the gallbladder and either the pancreas.
duodenum or jejunum. • Pancreaticoduodenal Trauma- A midline
incision is used to explore the abdomen.

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 Suturing to control bleeding, debridement of
devitalized tissue, and draining are the initial
therapies.

ESOPHAGEAL PROCEDURES
• Esophageal Hiatal Herniorrhaphy- When
intraabdominal pressure exceeds pressure
in the chest, the abdominal esophagus and a
portion of the stomach may slide through the
esophageal hiatus and into the thoracic INTESTINAL PROCEDURES
cavity. • Resection of the Small Intestine- An
• Esophagogastrectomy- Removal of the abdominal incision is made over the
lower portion of the esophagus and proximal suspected or known site of disease. After
stomach may be indicated to resect exposure, clamps are placed above and
malignant tumors, benign strictures, or below the diseased segment of the bowel
perforations at or near the esophagogastric and mesentery to avoid spillage. The
junction involved area is resected, and an end-to-end,
• Surgical Procedures for Esophageal end-to-side, or side-to-side anastomosis is
Varices- Sclerotherapy is usually attempted performed to restore continuity.
before more radical procedures are • Hemicolectomy, Transverse Colectomy,
performed. The lower esophagus may be Anterior Resection, and Total Colectomy-
transected and the distal segment Most surgical p cedures involve opening the
anastomosed with a circular stapler just abdomen, walling off the peritoneal cavity,
proximal to the stomach. incising and clamping at the points where
resection is to be carried out, and, finally,
GASTROINTESTINAL SURGERY reestablishing continuity by anastomosis.
• Gastroscopy- Gastroscopy involves the • Intestinal Stomas- is a surgically created
passage of a flexible fiberoptic gastroscope. opening, or stoma, that extends from a
This procedure is usually performed while portion of the bowel to the exterior via the
the patient is sedated, with a topical abdominal wall.
anesthetic applied in the oropharynx to • Ileostomy- the proximal end of the
control the gag reflex. transected ileum is exteriorized through the
• Gastrostomy- Establishment of a temporary abdominal wall.
or permanent opening in the stomach may be • Cecostomy- an opening is created in the
indicated for gastrointestinal decompression cecum and a tube is inserted for
or to provide alimentation for a prolonged decompression of the massive distention
period when nutrition cannot be maintained caused by colonic obstruction.
by other means. • Colostomy- An opening anywhere along the
• Gastric Resections- Total Gastrectomy, length of the colon to the exterior skin surface
Subtotal Gastrectomy( billroth procedure) creates an artificial anus
• Vagotomy- Vagotomy, the division of the
vagus nerves, may be recommended to
interrupt vagal nerve impulses, thus lowering
the production of gastric hydrochloric acid
and hastening gastric emptying. Vagotomy
can be performed at
• several different locations along the course
of the vagus nerve
• Bariatric Surgery- Bariatric surgery can be
performed as an open abdominal surgery or
as a laparoscopic procedure. The surgical
landmarks are altered in obese patients
because the body habitus is large and
extends beyond the borders of the average-
sized patient. Insufflation via Veress needle
may not be performed at the umbilicus.
(Gastroplasty,Gastric Bypass.)

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APPENDECTOMY
• The open abdominal approach involves a
muscle-splitting incision in the right lower
quadrant, over McBurney’s point. The blood
supply to the appendix is ligated and
severed. A crushing clamp is applied to the
appendiceal base, which is then ligated and
severed from the cecum.
• After creation of a peritoneal working space
with carbon dioxide (CO2 ), trocars are
placed, the laparoscope is inserted through
the infraumbilical incision, and the patient is
placed in
LAPAROSCOPIC APPENDECTOMY
• Trendelenburg’s position. Secondary trocars
are inserted in the suprapubic area and left
lower quadrant for placement of graspers
and dissectors. The appendix is located and
hemostatically dissected from the
mesoappendix with endoscopic clips or
staples. Endoloop ligatures are placed at the
base of the appendix, and endoscopic
scissors are used to transect.
COLLATERAL PROCEDURES
• Sigmoidoscopy- direct visual inspection of
the sigmoid and rectal lumens by means of a
flexible fiberoptic or rigid lighted
sigmoidoscope.
• Colonoscopy- provides visual inspection of
the lining of the entire colon.
• Polypectomy- usually performed through a f
tic colonoscope. Polyps, which are often
familial, may be single or multiple and are
easily excised at the base. The colonoscope
may be used intraoperatively to locate
polyps.
• Abdominoperineal Resection- (also known
as the Miles procedure) is a radical type of
colectomy and excision of the rectum and
anus performed for colon cancer or extreme
inflammatory disease.
• Low Anterior Colon Resection- With this
technique for low anterior colorectal
anastomosis, colorectal continuity is restored
and anal sphincter control is maintained
without necessitating a permanent
colostomy; with an abdominoperineal
resection, a permanent colostomy is
necessary.
ABDOMINAL TRAUMA
• Systematic Approach to Evaluation- When
dealing with abdominal trauma patients, the
first thought is hemorrhage or fecal spill.
Severe penetrating trauma can be
complicated by evisceration.
Ultrasonography, x-ray, and CT scan are
useful presurgical diagnostic tests to assess
the extent of abdominal injuries and to
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determine indications for surgical
intervention.
• Peritoneal Lavage- The peritoneal lavage
procedure is done under local anesthesia by
creating a 2-cm midline incision in one of two
planes: infraumbilical or supraumbilical (if the
patient is pregnant or has a fractured pelvis).
• Emergency Exploratory Laparotomy- The
surgeon makes a midline incision from
xyphoid to pubis in some cases. The surgeon
carefully displaces the abdominal contents
laterally to examine each angle of the
individual organs.
COMPLICATIONS OF ABDOMINAL SURGERY
• Patients are particularly prone to pulmonary
complications after abdominal surgery.
• subject to a variety of fluid and electrolyte
imbalances because they generally have a
nothing-by-mouth (NPO) status
postoperatively.
• Peritonitis and wound infection may result
after gastrointestinal surgery because of
spillage of contaminants from the lumen of
the gastrointestinal tract.
• Escherichia coli and Bacteroides fragilis are
the most common organisms; Clostridium
perfringens, the chief cause of gas
gangrene, can be found in the intestinal
tract.
• Adhesions are the most common cause of
postoperative intestinal obstruction.
OTHER ABDOMINAL SURGICAL PROCEDURE
• Anorectal Procedures
• Anoscopy, Proctoscopy, and Sigmoidoscopy
• Hemorrhoidectomy
• Incision and Drainage of an Anal Abscess
• Fistulotomy and Fistulectomy
• Fissurectomy
• Excision of Pilonidal Cysts and Sinuses
• Hernia Procedures
• Inguinal Herniorrhaphy
• Femoral Herniorrhaphy
• Umbilical Herniorrhaphy
• Ventral (Incisional) Herniorrhaphy
• Hiatal (Diaphragmatic) Herniorrhaphy
• Amputation of Extremities
• Amputations of the Lower Extremity
• Amputations of the Upper Extremity
• Rehabilitation
GYNECOLOGIC and OBSTETRIC SURGERY
Gynecology: General Considerations
• The emotional preparation of gynecologic
patients presents a special challenge to the
OR team.
• Anticipation of physical exposure, potential
loss of sexual function, infertility problems, or
 termination of pregnancy can create severe
anxiety.
• Some surgical procedures terminate
reproductive capability and produce
menopause.
• Patients must be able to express concerns,
ask questions, and receive reassurance and
support
DIAGNOSTIC TECHNIQUES
• pelvic examination includes inspection and
palpation of the external genitalia; bimanual
abdominovaginal and abdominorectal
palpation of the uterus, fallopian tubes, and
ovaries; and speculum examination of the
vagina and cervix
• Papanicolaou (Pap) smear has significantly
facilitated diagnosis of cervical cancer and
premalignant lesions.
• Schiller test involves staining the vaginal
vault and cervical squamous epithelium with
Lugol’s solution.
• Biopsy of the Cervix- Excisional Biopsy,
Incisional Biopsy, Cone Biopsy.
• Fractional Curettage- Tissue is obtained for
histologic examination by scraping the
uterine cavity. Fractional curettage
differentiates specimens between the
endocervix and the endometrium in a series
of two steps.
• Colposcopy- Illumination and binocular
magnification afforded by the
colpomicroscope permit identification of
abnormal epithelium to target for biopsy.
• Culdocentesis- blood, fluid, or pus in the
cul-de-sac is aspirated by needle via the
posterior vaginal fornix for suspected
intraperitoneal bleeding, ectopic pregnancy,
or tub ovarian abscess.
• Posterior Colpotomy- a transverse incision
is made through the posterior vaginal fornix
into the posterior cul-de-sac to facilitate
diagnosis by intraperitoneal palpation,
inspection of the pelvic organs, or
determination of free fluid, blood, or pus in
the pouch of Douglas.
• Tubal Perfusion
• Tubal Insufflation- Uterotubal insufflation
may be used to test the patency of the
fallopian tubes. It usually is done as an office
procedure to study infertility.
• Hysterosalpingography- X-ray study of the
uterus and tubes may afford further
evaluation of infertility after repeated
negative Rubin test findings.
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• Culdoscopy- culdoscope is introduced into
the peritoneal cavity via the p terior vaginal
fornix and pouch of Douglas. Some
gynecologists prefer culdoscopy to
investigate ovaries or posterior surfaces in
the lower pelvis.
• Hysteroscopy- rigid fiberoptic
hysteroscope, introduced vaginally through
the uterine cervix, provides direct inspection
of the interior of the uterus to diagnose
disease or treat conditions such as
menorrhagia and uterine fibroids
• Laparoscopy
VULVULAR PROCEDURES
• Total Vulvectomy- Basal cell carcinoma
usually does not metastasize but is often
locally extensive and prone to recur.
Treatment consists of wide total vulvectomy,
also without node dissection.
• Radical Vulvectomy with Bilateral
Inguinal-Femoral Lymphadenectomy-
Radical vulvectomy is performed for invasive
vulvar cancers or melanoma and is usually
done in one stage. Resection lines may vary
depending on the location and size of the
lesion
VAGINAL PROCEDURES
• Vaginectomy- Vaginectomy (partial or
complete) is performed for carcinoma in situ
or carcinoma of the vagina.
• Vaginoplasty- vagina may be constructed in
patients with congenital absence of the
vagina (Rokitansky syndrome) or, more
commonly, in those with stenosis after
radiation therapy or after surgical removal of
the vagina.
UTERUS
• Dilation and Curettage- The most
frequently performed gynecologic procedure,
dilation and curettage (D&C) is done for
diagnostic and/or therapeutic purposes. The
procedure is performed for women with
postmenopausal bleeding or symptoms
suggestive of endometrial cancer, even
when cytologic smear findings are negative.
• Intrauterine Thermal Balloon Ablation-
specialized electrically heated latex balloon
probe can be induced into the uterine cavity
through the cervical os to treat menorrhagia
• Vaginal Hysterectomy- performed for
severe uterine prolapse or prolapse
 accompanied by stress incontinence and for
patients with pelvic relaxation or a history of
myomas, irregular uterine bleeding, or a
treated premalignant lesion.
ABDOMINAL PROCEDURES
• hysteroplasty
• Myomectomy- myomectomy, single or
multiple fibroid tumors are removed from the
uterine wall in premenopausal women who
may still desire pregnancy.
• Abdominal Hysterectomy- The entire
uterus, including the cervix, is resected.
Normal ovaries are preserved for hormone
production whenever possible in women
younger than 45 years.
• Pelvic Exenteration- anterior exenteration
the reproductive organs, the distal part of the
ureters, the bladder, and the vagina are
removed. Posterior exenteration removes
the reproductive organs, sigmoid colon, and
rectum.
FALLOPIAN TUBE AND OVARIAN
PROCEDURES
• Tubal Ligation for Reproductive
Sterilization- Ligation may be performed
through a small transverse incision in the
pubic hairline area. An infraumbilical incision
is used for postpartum patients. This is
referred to as minilaparotomy.
• Salpingostomy- salpingostomy creates an
opening in a distally obstructed tube.
• Salpingolysis
• Tubal Anastomosis - A proximal obstruction
in the tube is resected
• Salpingectomy and Salpingo-
oophorectomy
• Ovarian Cystectomy
• Oophorectomy
• Urinary Stress Incontinence Procedures-
Urinary stress incontinence is the sudden,
involuntary, and intermittent release of urine
as a result of muscular changes around the
proximal urethra, bladder neck, and bladder
base.
• Marshall-Marchetti-Krantz Vesicourethral
Suspension- After mobilization through an
extraperitoneal abdominal approach into the
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prevesical space, the urethra and bladder
neck are suspended to the posterior border
of the symphysis pubis.
ABORTION
• Cerclage- Cerclage is not usually performed
after 26 weeks’ gestation because the cervix
is often too short to support suturing. Most
cerclage is performed as an ambulatory
procedure.
• Suction Curettage- Intrauterine contents
can be aspirated for elective voluntary
abortion or for incomplete natural abortion
(spontaneous abortion) within the first 20
weeks of pregnancy.
UROLOGIC SURGERY
Surgical Procedures of the Genitourinary
System
• Nephrectomy- Removal of a lobe or the
entire kidney is indicated when tumor,
disease, or traumatic injury has resulted in
the absence of renal function. The entire
kidney can be removed during a
laparoscopic procedure. Hand-assisted
laparoscopy (HALS) can use used.
• Nephrostomy or Pyelostomy- An incision
through the renal parenchyma or into the
renal pelvis may be necessary to establish
temporary or permanent drainage when an
obstruction prevents the flow of urine from
the kidney
• Pyeloplasty- Revision or reconstruction of
the renal pelvis is performed to relieve an
anatomic obstruction in the flow of urine by
creating a larger outlet from the renal pelvis
into the ureter.
• Renal Revascularization- Stenotic lesions
of renal arteries are surgically correctable
causes of hypertension. Renovascular
reconstructive procedures (renal
angioplasty) are designed either to improve
blood flow through the stenotic area to the
kidney or bypass the stenotic area.
• Dialysis- The treatment modality alleviates
the acute manifestations of uremia and
controls many of the chronic long-term
complications of end stage renal disease.
• Nephrolithotomy or Pyelolithotomy- A
nephroscope may be used during the
surgical p dure for direct visual examination
of the nephrons to locate and remove
residual calculi.
• Extracorporeal Shock-Wave Lithotripsy-
Shock waves delivered directly over the
kidney may injure the renal tissue causing
the development of hypertension or chronic
renal disease.
• Ureteroscopy— These scopes are
introduced percutaneously or c cally.
Biopsies of tumors can be performed, and
strictures can be corrected by balloon
dilation.
• Ureterolithotomy- If the calculus is high in
the ureter near the kidney, the patient is
positioned for a lateral flank incision below
the twelfth rib. An abdominal incision is used
 to reach a calculus in the lower segment near
the bladder.
• Cystoscopy- Cysto is a visual examination
of the interior walls and contents of the
bladder.
• Suprapubic Cystostomy- With a reduction (CR).
suprapubic cystostomy, urinary drainage
from the bladder is established via a catheter
inserted through a suprapubic incision or
trocar puncture into the bladder.
• Cystectomy- In a cystectomy, the bladder is
removed for invasive malignant disease. The
bladder can be removed by an open
procedure or by robot-assisted laparoscopy.
• Urethroplasty- Reestablishment of
continuity without stricture is the ultimate
objective after a traumatic urethral injury and
is usually associated with pelvic fractures in
males.
• Orchiectomy- In this procedure, bilateral
oblique incisions in the inguinal canals
extend into the upper anterior surface of the
scrotum over the testes. The testes are
removed from the scrotum after ligation of
the spermatic cords at the external or internal
inguinal rings.
• Vasectomy- In a vasectomy, a segment of
each vas deferens is removed and sent to
the pathology department in individually
labeled specimen cups
• Vasovasostomy- Recannulization of the
vas deferens for the restoration of fertility
requires an unobstructed anastomosis. The
vas deferens has a tough 2-mm outer
diameter and an inner diameter of 1 mm or
less at the distal end, as well as dilation at
the proximal end.
• Transurethral Prostatectomy-
Transurethral resection, also referred to as
transurethral resection of the prostate
(TURP), involves the removal of all or part of
the glandular tissue within the prostatic
capsule by electroresection through the
urethra
• Adult Male Circumcision- Difficulty in the
retraction of the foreskin is referred to as
phimosis. Paraphimosis occurs when the
foreskin retracts to expose the glans and
cannot be repositioned back. These
conditions may necessitate circumcision or
removal of the foreskin to prevent necrosis
and gangrene.
• Penectomy- The penis may be partially or
completely resected because of neoplasm or
trauma. A partial penectomy may allow the
patient enough length for upright voiding.
Cosmetic reconstruction may be possible in
some patients. Invasive disease may
necessitate a complete penectomy, including
removal of the scrotum and testes
(orchiectomy).
• Penile Prosthesis- Implantation of a penile
prosthesis as treatment for organic
impotence can enable some men to achieve
a satisfactory return of sexual activity within
4 to 6 weeks postoperatively.
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ORTHOPEDIC SURGERY
• Closed Reduction- A fracture may be
manipulated (set) to replace the bone in its
proper alignment without opening the skin.
This technique is referred to as a closed
• Skeletal Traction- Traction is the pulling
force exerted to maintain proper alignment or
position. In skeletal traction the force is
applied directly on the bone after insertion of
pins, wires, or tongs placed through or into
the bone.
• External Fixation- are used for the
treatment of selected types of skeletal
injuries, especially to the pelvis and
extremities, with marked soft tissue loss and
instability.
• Open Reduction and Internal Fixation
(ORIF)- exposes the fracture site for
realignment under direct visualization;
closed reduction sometimes precedes the
insertion of an internal fixation device. The
fracture is reduced to align fragments.
• Arthrodesis- Fusion of a joint may be
achieved by removing the articular surfaces
and securing bony union or by inserting a
fixation implant that inhibits motion.
Arthrodesis may be performed after
resection of a recurrent benign, potentially
malignant, or malignant lesion that involves
the ends of the bones and joint.
• Arthroplasty- Arthroplasty (reconstruction
of a joint) may be necessary to restore or
improve range of motion and stability or
relieve pain. This may be done by
resurfacing, reshaping, or replacing the
articular surfaces of the bones.
• Arthroscopy- visualization of the interior of
a joint through an arthroscope, allows
diagnosis and conservative treatment of
some cartilaginous, ligamentous, synovial,
and bony surface defects.
• Arthrotomy- (i.e., incision into a joint) may
be necessary to remove bone or cartilage
fragments or to repair a defect in the
synovium or joint capsule. Synovectomy may
be the procedure of choice for relief of pain
and control of inflammation in a rheumatoid
arthritic joint.
• Cast Application- A cast is a rigid form of
dressing used to encase and support a part
of the body. It supports and immobilizes the
part in optimum position until healing takes
place. A cast usually includes the joints
above and below the affected area.
COMPLICATIONS AFTER ORTHOPEDIC
SURGERY
▪ Embolus- Fat embolism is possible after
fracture of a long bone or crush injury.
Thromboemboli can result from deep vein
thrombosis, causing pulmonary emboli. Any
vessel wall injury can cause this event.
Rarely a bolus of bone cement can enter the
venous system and travel to the patient’s
lungs.
 ▪ Compartment Syndrome- Edema,
hematoma, and seroma may form between
tissue layers of the fascial plane, causing
compartment syndrome. The pressure from
prolonged swelling results in further tissue
destruction and necrosis that can lead to
toxicity and death
NEUROSURGERY OF THE BRAIN AND
PERIPHERAL NERVES
Surgical Procedures of the Cranium
▪ Craniectomy- removal (-ectomy) of a portion
of the bones of the skull (cranium).
▪ Craniotomy- Scalp, bone, and dural flaps
are raised to expose a large area of the
cerebrum for exploration, definitive
treatment, or excision of lesions within the
brain.
▪ Cranioplasty- Traumatic or surgically
created skull defects are corrected with
autogenous bone grafts or a synthetic or
titanium prosthesis. Large defects in the
anterior or middle fossae are covered for
protection of the brain and for cosmetic
effect.
OPHTHALMIC SURGERY
• Blepharoplasty- redundant folds of skin and
herniated pockets of fat are removed, and
defects in the muscle layer are repaired
• Enucleation- complete removal of the e ball
and the severing of its muscular
attachments. The muscle stumps are
preserved, with the space between the
stumps forming a pocket for the spherical
plastic artificial eye
• Evisceration- removes the contents of the
eyeball only; the outer sclera and muscles
are left intact for attachment to a prosthesis.
This procedure reduces the danger of
transmitting an intraocular infection to the
orbit and brain.
• Exenteration- removal of the entire eye and
orbital contents, including tendon, fatty, and
fibrous tissues. This procedure is performed
for a malignant tumor of the lids or eyeball
that has extended into the orbit.
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• Corneal Transplantation (Keratoplasty)- a
damaged cornea is removed and replaced
with a healthy cornea from a human donor.
• Extracapsular Extraction- the lens is
delivered through a small incision in the
region of the limbus (the junction of the
cornea and sclera).
• Intracapsular Extraction- The entire lens,
intact within its capsule, is delivered through
a moderate-sized incision made in the region
of the limbus. Before delivery, an iridectomy
or multiple iridotomies are performed, chiefly
to prevent iris prolapse and to preserve
communication between the anterior and
posterior chambers.
• Repair of Detached Retina- Reattachment
is effected only by surgical intervention. The
retinal defect is sealed off, and often the
subretinal fluid is drained. The specific
procedure used to achieve retinal
reattachment is determined by the type and
location of the detachment.the
• Vitrectomy- Vitrectomy is the deliberate
removal of a portion of the vitreous humor,
also called vitreous body, that fills the space
between the lens and the retina.
Therapeutically it is performed for vitreal
opacities, vitreal hemorrhage, and certain
types of retinal damage or detachment. In
addition to other causes, endophthalmitis
(i.e., inflammation of the internal tissues of
the eyeball) and the presence of an
intraocular foreign body may result in vitreal
opacity.
PLASTIC AND RECONSTRUCTIVE SURGERY
• Skin and Tissue Grafting- Denuded areas
of the body are resurfaced by transplanting
or transferring segments of skin and other
tissues from an uninjured area (donor site) to
the injured area (recipient site). The plastic
surgeon prefers to transfer tissues of
compatible color, texture, thickness, and
hair-bearing characteristics.
• Pedicle Flaps- The pedicle, which is the
attachment of elevated tissue to the donor
site, must contain a vascular bundle to
maintain blood supply to the tissue. Pedicle
flaps are constructed from several types of
tissues and sources of vascular bundles.
Nasal reconstruction is commonly done this
way
• Replantation of Amputated Parts-
Replantation may be attempted to salvage a
traumatically amputated digit, hand, or entire
upper extremity. A severed foot or lower
extremity presents more formidable
problems because of the functional necessity
for weight bearing
• Soft Tissue Reconstruction- This
technique ensures consistent skin color,
texture, and hair-bearing characteristics.
• Blepharoplasty- Redundant skin and/or
protruding orbital fat is excised to correct
deformities of the upper or lower eyelids of
one or both eyes. Blepharochalasis (loss of
elasticity of the skin of the eyelids) can occur
at any age and usually is of unknown cause
 • Rhinoplasty - Reshaping of the nose,
although usually performed for cosmetic
alteration desired by the patient, may be
necessary to correct defects caused by
trauma or surgical resection of neoplasms
• Hair Replacement - Hair follicles can be
transplanted from the posterior aspect of the
scalp to bald or balding areas. Hundreds of
micrografts (4 mm) and minigrafts (4.5 mm)
are implanted in staged rows over the entire
bald area to change the hairline.
• Liposuction - A blunt, hollow, curved or
straight metal cannula (Mercedes cannula)
measuring 1.5 to 6 mm with multiple
openings in the distal shaft connected to a
suction machine is inserted through small
skin incisions
• Augmentation Mammoplasty - Inflatable
implants are inserted under breast tissue or
the underlying pectoralis muscles and then
filled with sterile saline solution through self-
sealing valves.
OTORHINOLARYNGOLOGIC AND HEAD AND
NECK SURGERY
• Removal of a Foreign Body- Removing a
foreign body from the outer canal is
performed most frequently in children. The
object is washed out or removed to prevent
purulent infection
• Mastoidectomy- the eradication of mastoid
air cells, may be indicated to relieve
complications of acute or chronic mastoiditis.
Mastoidectomy is more commonly
performed in conjunction with a not distant.
reconstructive procedure.
• Tympanoplasty - refers to any procedure
performed to repair defects in the eardrum
and/ or middle ear structures for the purpose
of reconstructing sound conduction paths.
• Labyrinthectomy- vestibular labyrinth is
removed from the inner ear to correct
incapacitating vertigo. This results in loss of
vestibular function and hearing.
• Turbinectomy- Chronic engorgement of the
middle and/or inferior turbinate causes nasal
congestion and rhinorrhea. Rhinitis is
frequently an allergic reaction.
• Polypectomy- Polyps usually are bilateral,
but they may be unilateral, single or multiple,
and they frequently are infected. In addition
to obstructing ventilation, they may obstruct
the sense of smell if the olfactory epithelium
is blocked.
• Rhinoplasty- procedure to correct deformity
of the nose, may be performed by a
rhinologist or a plastic surgeon. It is a major
procedure involving reconstruction and
molding of the bones and cartilages
• Parotidectomy- excision of a parotid gland,
is performed through an incision in the neck
below the angle of the mandible and
extending upward to one or both sides of the
ear
• Total Glossectomy- All of the tongue and
often the floor of the mouth are resected
D.JUAN
• Adenoidectomy- removal of hypertrophied
adenoid tissue from the nasopharynx and
behind the posterior choanae, may be
performed in adults to relieve upper airway
obstruction. This is more commonly
performed in children, often to prevent
recurrent otitis media. Adenoid tissue usually
atrophies after adolescence.
• Tonsillectomy - Chronically infected or
hypertrophied tonsils are most frequently
removed in childhood.
• Gingivectomy - Portions of the gingiva,
mucous membrane, and underlying soft
tissue that covers the alveolar process and
surrounds the teeth are excised to remove
deep pockets of plaque, calculus, and
inflamed soft tissue.
• Tracheotomy and Tracheostomy-
Tracheotomy is an incision into the trachea
below the larynx. Tracheostomy is the
formation of an opening into the trachea
where a tube is inserted to help the patient
breathe.
• Thyroidectomy- During all thyroidectomy
procedures, care is exercised not to damage
the laryngeal nerves and parathyroid glands.
• Radical Neck Dissection- This procedure
gives the patient with cancer of the cervical
lymphatic chain a chance for cure and arrest
of spread. When metastasis is known to be
present or is highly suspected because of the
location or stage of the malignancy, the
surgical procedure is predicated on the
assumption that metastases are regional and
• Resection of Nasal or Paranasal Sinus
Tumors- Radical craniofacial resection may
be indicated to remove gigantic benign nasal
dermoid tumors and malignant tumors of the
paranasal sinuses. In a one-stage
procedure, all involved soft tissue is excised
with simultaneous correction of the
underlying skeletal structure.
• Reduction of Nasal Fractures- Fracture of
the nasal bones and septum often
accompanies other trauma to the head, such
as a blowout fracture of the orbit (see earlier).
If the zygoma or maxilla is involved,
reduction may be accomplished through a
small incision anterior to the ear and superior
to the zygomatic arch.
• Intermaxillary Fixation of Fractures- After
closed or open reduction, fractures of the
maxilla and mandible are usually
immobilized by interdental wiring if the
patient has upper and lower teeth.
• Mandibular Fractures- Some fractures of
the mandible can be immobilized by transoral
placement of noncompression miniplates.
This technique obviates the necessity of
interdental wiring. Vitallium, titanium, or
stainless steel plates and screws are used
for rigid fixation.
THORACIC SURGERY
• Mediastinoscopy- Mediastinoscopy
uncovers mediastinal lymph nodes for direct
visualization and biopsy.
• Thoracostomy- Closed thoracostomy is
performed to establish continuous drainage
of fluid from the chest (usually purulent from
sepsis or drainage of blood) or to aid in
restoring negative pressure in the thoracic
cavity. It involves insertion of a tube through
an intercostal space via a trocar and cannula.
• Thoracoscopy- Thoracoscopy provides
visualization of the pleural space, parietal
and visceral pleurae, mediastinum,
pericardium, and thoracic wall.
• Extracorporeal Membrane Oxygenator-
An extracorporeal membrane oxygenator
(ECMO) is used as a resuscitative device for
adults or children who have potentially
reversible respiratory and/or cardiac failure.
8 It also is commonly used to prolong
extracorporeal circulation when the patient is
in distress after removal from
cardiopulmonary bypass.
• Thoracotomy- An incision through the
thoracic wall (i.e., thoracotomy) is indicated
for drainage of pleural spaces, exploration of
the thoracic cavity, or cardiac and pulmonary
procedures. Thoracic surgical procedures,
exclusive of cardiac procedures, include
exploratory thoracotomy, open thoracotomy,
and open chest drainage.
• Lung Resection- Generally the indications
are neoplasms; e matous blebs; and fungal
infection, localized residual lung abscess,
tuberculosis, and/or bronchiectasis resistant
to nonsurgical treatment. 9Neoplasms are
the predominant indication.
• Thoracentesis- Air or blood in the pleural
cavity may be detected on x-ray and
aspirated by a needle and syringe. A chest
tube may be inserted into the pleural space
percutaneously for closed thoracostomy
drainage. If bleeding persists, the chest is
opened and vessels are ligated or repaired.
COMPLICATIONS
• Continuous movement of the chest causes
postoperative pain.
• The plan of care should include preoperative
teaching of breathing techniques to assist the
patient in clearing airway secretions.
• Chylothorax, the leakage of chyle from the
thoracic duct of the lymphatic system into the
pleural space, is a potential complication of
thoracic surgery.
CARDIAC SURGERY
Commonly Used Incisions for Cardiac Surgery
• Median Sternotomy is used for operations
of the heart, ascending aorta, and anterior
mediastinal structures including the thymus
and tumors that lie anterior to the heart.
• Paramedian Thoracotomy- incision on the
left side may also be used to biopsy lymph
nodes that reside in the aortopulmonary
window that cannot be reached with a
D.JUAN
mediastinoscope or computed tomography
(CT)guided percutaneous needle.
• Transsternal Bilateral Thoracotomy—
This incision is referred to as a clamshell and
is mostly used for bilateral lung transplants.
This incision is less commonly used and
causes more discomfort for the patient.
• Anterolateral or Posterolateral
Thoracotomy- Anterolateral or
posterolateral incisions may be preferred for
some cardiac procedures such as valve
procedures.
CARDIAC SURGICAL PROCEDURES
• Cardiopulmonary Bypass- CPB is the
technique of oxygenating and perfusing
blood by means of a mechanical pump-
oxygenator system. This apparatus
temporarily substitutes for the function of the
patient’s heart and lungs during cardiac
surgery. CPB is used for most intracardiac
(open heart) and coronary artery procedures.
• Components of a Bypass System-
Oxygenator, Heat Exchanger, Pump,
Perfusion, De-airing.
• Restorative Valve Procedures- Restorative
and reparative valve surgery is the preferred
procedure for most valve diseases.
Valvuloplasty and a plasty are valve-sparing
procedures to maintain structural integrity
and ventricular function.
• Valve Replacement- Mechanical Valves,
Biologic Valves, Mitral Valve Replacement,
Aortic Valve Replacement..
• Coronary Artery Bypass Graft- For
coronary artery bypass grafting (CABG),
single or multiple arterial bypasses are done,
depending on the number of vessels affected
and the degree of obstruction present.
• Coronary Artery Angioplasty- Coronary
artery angioplasty procedures usually are
performed in the cardiac catheterization
laboratory (cath lab) or special interventional
procedures room in the radiology
department.
• Percutaneous Transluminal Coronary
Angioplasty.- performed under fluoroscopy
with image intensification. Balloon dilation of
the coronary arteries may be the procedure
of choice for select patients with significant
atherosclerotic narrowing in a major coronary
artery
• Laser Angioplasty- An argon laser probe, a
neodymium:yttrium aluminum garnet
(Nd:YAG) optical fiber, or a pulsed excimer
laser may be used for laser angioplasty.
• Intracoronary Stent- A stent may be
inserted to act as a b tress to keep an artery
open. The coronary artery to be stented
should be at least 3 mm in diameter.
• Transmyocardial Revascularization
(TMR) - performed through a left
thoracotomy incision without the use of CPB.
• Cardiac Dysrhythmias
• Maze Procedure- The maze procedure,
named for the puzzle-like pattern
appearance of the incisions introduced by
 James Cox in 1987, is a cure for AF by
interrupting the impulses that cause the
dysrhythmias and preserves the contractility
of the atria.
• Radiofrequency Ablation- This treatment
of AF involves the use of a surgical probe
that creates a series of linear lesions.
• Cryoablation- This procedure is used to
treat the same dysrhythmias as
radiofrequency ablation but uses a
refrigerant to freeze the affected area to –
112° F (–80° C)
• Mechanical Assist Devices
• Cardiac Pacemaker- A pacemaker consists
of a pulse generator, which produces
electrical impulses, and leads to carry
impulses to stimulating electrodes placed in
contact with the heart
• Cardioverter-Defibrillator- The automatic
implantable cardioverter-defibrillator (ICD)
has the capability of recognizing potential
life-threatening episodes of ventricular
tachycardia or fibrillation
• Intraaortic Balloon Pump- is a left
ventricular supportive device used to assist a
patient with prolonged myocardial ischemia,
reversible left ventricular failure, or
cardiogenic shock.
• Ventricular Assist Device (VAD) - to wean
patients from CPB when the IABP, drugs,
and/or cardiac pacing are ineffective, to
support circulation after postinfarction
cardiogenic shock or traumatic myocardial
contusion, and to provide a temporary bridge
for support before transplantation
• Extracorporeal Membrane Oxygenator-
used as a resuscitative device for patients
who have potentially reversible respiratory
and/or cardiac failure.
• Artificial Heart- Clinical trials are in process
to test an artificial heart that can be
permanently implanted to maintain
circulation in the patient with irreparable
myocardial damage or end-stage cardiac
disease who does not meet the criteria for
cardiac transplantation. A total artificial heart
also could be used as temporary support
while the patient is awaiting a transplant.
COMPLICATIONS:
• The most common complication of cardiac
surgery with or without CBP is stroke.
• Low blood pressure (50-60 mm Hg) during
bypass can lead to ischemic cerebrovascular
accidents of the brain. Hypertensive
episodes can lead to hemorrhagic brain
insults.
D.JUAN
• Excessive bleeding can result in cardiogenic
shock and alteration of the body’s clotting
mechanism
• Postoperative myocardial infarctions (MIs)
are infrequent; however, an MI can lead to
cardiogenic shock
• Organ failure is always a concern with
cardiac surgery and CPB. Organ failure can
affect any organ system, but is most
commonly seen in the kidneys.
• Acute tubular necrosis (ATN) can result from
atherosclerosis of the renal arterial system,
leading to kidney failure
• Adult respiratory distress syndrome (ARDS)
and other acute respiratory disorders
complicate the postoperative outcomes of
some patients undergoing cardiac surgery.
• Wound infections of the sternum can also
lead to horrific sepsis and are managed
surgically
• Cardiac tamponade occurs when blood and
fluids build up around the heart
• Electrolyte imbalance in magnesium,
potassium, and to a lesser extent, calcium,
can lead to serious cardiac dysrhythmias
such as sinus bradycardia, supraventricular
tachycardia (SVT), ventricular tachycardia
(VT), atrial fibrillation, atrial flutter, and
ventricular fibrillation (VF)
VASCULAR SURGERY
• Vascular Grafts- Biologic or synthetic
prosthetic vascular grafts are required to
bypass a vascular obstruction or reconstruct
vessels. These substitute conduits for blood
flow vary in length, diameter, and
configuration to meet the requirements of
each situation
• Percutaneous Transluminal Angioplasty-
PTA is performed under local anesthesia and
fluoroscopy, often in the interventional
radiology department by a radiologist, in the
angiography or cardiac cath laboratory by a
cardiologist, or in the OR by a surgeon.
• Balloon Angioplasty
• Atherectomy- In an atherectomy, catheter-
mounted instruments are used for
transluminal removal of atherosclerotic
plaque
• Thrombectomy and Embolectomy- This
procedure may be performed with
fluoroscopy to selectively cannulate vessels.
Different types and sizes of catheters and
balloons may be used when the blockage is
in a native vessel or an artificial graft
• Thrombolytic Therapy- In thrombolytic
therapy, streptokinase, urokinase, or tissue-
type plasminogen activator (t-PA) may be
administered by local bolus infusion or x-ray–
directed catheter into the occluded vessel or
directly injected into the thrombus over a
period of 12 to 24 hours.
• Vascular Surgical Procedures
• Arterial Bypass