Hello Dear to be Surgeons,

For Four year candidates, 400 General Surgery And 100 Sub specialty cases and
for two year general surgery candidates, 200 General Surgery and 100 Sub
Speciality cases are MENDATORY.
You have to update every 3 weeks. Cannot enter back date more than 3 weeks.
During my residency I used to read surgical procedure I scrub in, from
Farquharson and Kirk, and write in a word file. Only operative findings change for
the next time you enter that case in your log book . that will save time and
energy.

The idea is to keep the entrees of simple cases the most so that you can explain
them easily during your log book station in TOACS ,be it IMM or FCPSII. So not
enter cases like bariatric or robotic surgeries that will make you in trouble when
examiner opens your elog book and decides to give you tough time.

Keep it crisp and simple

Work hard but work Smart too 

Best of luck and best Regards,

Dr. Anum Arif

MBBS, FCPS
GENERAL SURGERY
Aga Khan University Hospital |Karachi, Pakistan

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 GENERAL SURGERY

AXILLARY ABSCESS I and D

operation: debridement of left axillary wound findings: wound in left axilla after
bursting of axillary abcess, filled with pus procedure: 1. general anesthesia given
2. patient's left arm, axilla and left side of chest and neck scrubbed and draped 3.
all dead necrotic material excised and all pus drained gently taking care not to
injure the axillary vasculature 4. wound washed with hydrogen peroxide and
normal saline and cavity packed with pyodine soaked ribbon gauze and aseptic
dressing done 5. patient woke up and moved to recovery.

HEMORRHOIDECTOMY
OPERATIVE FINDINGS: internal hemorrhoids at 3 &7 O’clock PROCEDURE: 1.
Spinal anesthesia given. 2. Patient placed in lithotomy position with some head
down tilt. 3. Disposable proctoscope placed in the anal canal and hemorrhoids
grasped with artery forceps and retracted outward. 4. small v shaped incision
given at base of hemorrhoids beyond anal verge and anal mucosa separated from
the muscles using guaze piece. A suture ligature is placed at proximal aspect of
vascular pedicle using vicryl 0. 5. then diathermy is used to excise the
hemorrhoidal bundle. 6. Repeated the procedure for other hemorrhoid. 7.
Complete hemostasis ensured. 8. T bandage dressing applied.

LUMPECTOMY
Operation: Excision of lump Operative findings: lump in the left breast 7x5cm in
size at 10 0 clock position. Procedure: 1. General anesthesia given 2. Left breast
scrubbed and draped 3. Circumareolar incision given at 10 0 clock over the lump.
4. Subcutaneous tissue diathermized and lump dissected from surrounding breast
tissue and excised using sharp and blunt dissection. 5. Hemostasis secured. 6.

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Subcutaneous fat closed with vicryl 2-0 interrupted and skin closed with
subcuticular vicryl 3-0. 9.
Aseptic dressing done.
SEBACEOUS CYST
operation: sebaceous cyst excision operative findings: sebaceous cyst on anterior
chest wall in midline at the level of nipples procedure: 1. patient placed supine 2.
anterior chest scrubbed and drapped 3. local anesthesia infiltrated by injection
xylocaine with adrenaline 4. elliptical incision given over the swelling including the
punctum 5. swelling dissected from surrounding tissue using sharp and blunt
dissection 6. swelling excised as whole 7. cavity washed with normal saline,
hemostasis secured and again washed with povidone iodine 8. subcutaneous fat
closed with vicryl 3-0 interrupted and skin closed with prolene 3-0 mattress
sutures 9. aseptic dressing done 10. patient moved to recovery.

OPERATION: EMERGENCY INGUINAL HERNIA REPAIR + RESECTION AND

ANASTOMOSIS
Operative Findings: 1) Right sided strangulated indirect Inguinal Hernia 2)
Contents of hernia sac: gangrenous 8cm loop of distal ileum around 35cm from
ileocecal junction. 3) a band constricting that bowel loop in upper portion of
scrotum Operative Notes: 1) Spinal anesthesia given. The patient scrubbed and
draped from the level of nipples above to the mid thighs involving the penis and
scrotum and to the right anterior superior iliac spine laterally. 2) Oblique inguinal
incision given. 3) The skin along with the fat and fascia opened up with securing
hemostasis. External oblique aponeurosis and superficial inguinal ring identified.
External oblique aponeurosis incised in the line of its fibers and then split and
structures beneath carefully separated from its deep surface. 4) Ilioinguinal nerve
identified and divided. 5) Swab on stick used to remove the adherent fascia from
the inguinal ligament inferiorly to the conjoint tendon superiorly. 6) The
spermatic cord lifted up using pubic tubercle as the landmark. 7) Indirect inguinal
hernia sac opened and all fluid that was coming from the distal sac was aspirated.
Bowel loops withdrawn from the distal sac and warm saline soaked abdominal
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 sponges applied, gangrenous bowel resected and ileoileal, isoperistaltic
anastomosis done via GIA stapler about 25cm from ileocecal junction. Inguinal
incision extended obliquely towards right side. Internal ring also widened laterally
and Bowel returned to peritoneal cavity. 8) Sac is then ligated with vicryl 3/0 and
amputated. Right orchidectomy done and cord divided at level of internal ring. 9)
internal ring closed with vicryl and The external oblique aponeurosis closed using
a running continuous stitch in lateral to medial direction and the fat and fascia
closed with Vicryl 3/0. 10) The skin closed with Vicryl Rapid 3/0. 11) Aseptic
dressing applied /

LEFT SIDED MODIFIED RADICAL MASTECTOMY

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

FISTULECTOMY

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operative findings: 1. internal openings at 5 & 7 0 clock 2. external openings at 5,
6 & 7 0 clock position around 2.5 cm from the anal verge 3. procedure: 1. spinal
anesthesia given 2. patient place in lithotomy position 3. perianal area scrubbed
and drapped 4. DRE and proctoscopy done 5. probe inserted in the tracts and
taken out through internal opening 6. fistulous tracts excised using diathermy and
all the granulation tissue curretted 7. hemostasis secured. 8. cavity washed with
povidone iodine and normal saline 9. cavity packed and aseptic dressing done.

FISTULOTOMY
operative findings:
procedure: 1. spinal anesthesia given 2. patient place in lithotomy position 3.
perianal area scrubbed and drapped 4. DRE and proctoscopy done 5. probe
inserted in the tracts and taken out through internal opening 6. fistulous tracts
laid open using diathermy and all the granulation tissue curretted 7. hemostasis
secured 8. cavity washed with povidone iodine and normal saline 9. cavity packed
and aseptic dressing done.

LAPROSCOPIC MODIFIED GRAHAM'S PATCH REPAIR OF GASTRIC PERFORATION

operative findings: 1. peritoneal cavity filled with pussy flakes 2. perforation in
distal part of stomach on anterior wall about 0.5 mm procedure: 1. General
anesthesia given 2. abdomen scrubbed and drapped from level of nipples above
to suprapubic area below 3. nasogastric tube passed and stomach deflated. 4)
Pneumoperitoneum established via open method. 10 mm infra umbilical incision
given. Trocar inserted. insufflation using CO2 and insertion of camera done. Intra
abdominal pressure maintained of 10-14mmHg. 5) The patient is placed in reverse
Trendelenburg position 6. Placement of three other ports .One 10mm port in the
subxiphoid position with the intra-abdominal portion located to the left of
falciform ligament. Two 5mm ports 2 finger breadths below the costal margins
bilaterally and close to midclavicular line. A laproscope is used to explore the

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abdomen for adhesions and potential injuries that may have occurred during port
placement. 7. The fibrin seal between the under-surface of the liver, gall- bladder
and the perforated ulcer is gently divided to expose the ulcer. The anterior aspect
of the first part of the duodenum and distal stomach inspected first. Overlying
omentum is peeled away and gastric perforation visualized and multiple biopsies
taken from the ulcer. 8. Closure is achieved by the insertion of three interrupted,
vicryl sutures. Generous bites, which pass through the entire thickness of the gut
wall taken. Care taken to ensure that they do not catch the posterior wall. Sutures
inserted in the long axis of the gut to avoid narrowing. The closure then
reinforced with an omental on-lay patch, a ‘modified Graham patch'. 9. peritoneal
cavity thoroughly irrigated with normal saline and suction done 10. one drain
placed over the repaired area and one in pelvis and secured with silk sutures 11.
gas stopped and ports opened to allow escape of gas then ports removed 12.
fascial defect at infraumblical incision closed with vicryl 0 on J needle and skin
closed with staples 13. remaining incisions closed at skin only with staples 14.
aseptic dressing done.

LAPAROSCOPIC CHOLECYSTECTOMY
Findings: 1) Gall bladder with multiple stones 2) Normal Calot’s triangle anatomy.
Procedure: 1) General anesthesia given. Patient scrubbed and draped from the
nipples above to supra pubic area below and mid axillary line laterally on left and
to posterior axillary line on right. 2) Nasogastric tube passed and stomach
deflated. 3) Pneumoperitoneum established via open method. 10 mm infra
umbilical incision given. Trocar inserted. insufflation using CO2 and insertion of
camera done. Intra abdominal pressure maintained of 10-14mmHg. 4) The patient
is placed in reverse Trendelenburg position slightly rotated to the left. 5)
Placement of three other ports .One 10mm port in the subxiphoid position with
the intra-abdominal portion located to the right of falciform ligament. A 5mm
port 2 finger breadths below the right costal margin and close to midclavicular
line. A 5mm port laterally along the anterior axillary line. A laproscope is used to
explore the abdomen for adhesions and potential injuries that may have occurred
during port placement. 6) A crocodile forcep is inserted through the lateral 5mm
to retract fundus of gall bladder towards diaphragm. Neck of gall bladder is

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retracted by plain forceps towards right iliac fossa exposing calot’s triangle using
the middle 5mm port. 7) A hook cautery is used to carefully incise the peritoneum
overlying the calot’s triangle both anteriorly and posteriorly 8) All remaining
connective tissue is dissected out of calot’s triangle using blunt dissection by
marryland dissector and hook cautery as needed. 9) Clips are then placed around
the cystic duct – two below and one above and one clip around the cystic artery is
placed. 10) Scissors are then used to cut the duct and hook diathermy used for
cystic artery. 11) The gall bladder is then dissected off the liver and a bag is used
to remove it out of the abdomen through the subxiphoid port. 12) Homeostasis
secured. 13) The ports are removed and gas stopped to remove free gas. 14) The
fascial defect is closed at the umbilicus and subxiphoid with Vicryl 0 on J needle.
Skin closed with staples. 15) The rest of the ports are closed at the skin only with
staples. 16) Aseptic dressings are placed and the patient woken up.

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

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 PARAUMBLICAL HERNIA REPAIR
OPERATIVE FINDINGS: Paraumblical hernia with defect of almost 6cm. Contents
of sac: viable gut PROCEDURE: 1)Abdomen scrubbed and drapped from the level
of nipples above to groin below. 2)Elliptical incision given including the umblicus.
3)Sharp dissection through skin and subcutaneous tissue to underlying fascia
done. 4)Hernia sac identified and opened and contents visualized and returned to
peritoneal cavity. 5)5cm clearance of fascial defect done with careful finger sweep
in sub fascial layer. 6)Primary repair of fascial defect done with prolene 1. 7)Onlay
placement of prolene mesh 15x15cm done and stabilized with mesh stapler
8)Radivac drain 16 fr placed and secured with silk suture 9)Subcutaneous fat
closed with vicryl 2/O 10)Skin closed by skin stapler 11)Aseptic dressing done
12)Patient woke up and moved to recovery.

SINUS TRACT EXCISION

operative findings: 1. no communication with anal canal 2. sinus opening at 5 0
clock position around 2.5 cm from the anal verge 3. direction of tract posteriorly
upwards procedure: 1. spinal anesthesia given 2. patient place in lithotomy
position 3. perianal area scrubbed and drapped 4. DRE and proctoscopy done to
see any internal communication with the anal canal 5. probe inserted in the tract
6. whole of the tract excised using diathermy 7. hemostasis secured 8. cavity
washed with povidone iodine and normal saline 9. cavity packed and aseptic
dressing done.

TRUCUT BIOPSY
operative findings: left breast lump at 5 0 clock position 4x4cm in size procedure:
1. left breast scrubbed and draped 2. local anesthesia given by injection xylocaine
with adrenaline 3. a small stab incision given with blade 11 4. trucut biopsy needle
14 guage inserted and multiple biopsies taken and collected in formaline
container 5. aseptic dressing done.

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

EXCISION OF LUMP
Operative findings: lump in the left breast 2x2cm in size at 11 0 clock position.
Procedure: 1. General anesthesia given 2. Left breast scrubbed and draped 3.
Circumferential incision given at 11 0 clock over the lump. 4. Subcutaneous tissue
diathermized and lump excised using sharp and blunt dissection. 5. Hemostasis
secured. 6. Subcutaneous fat closed with vicryl 3-0 interrupted and skin closed
with subcuticular vicryl 3-0. 9. Aseptic dressing done.
EXPLORATORY LAPROTOMY+ RELEASE OF ADHESIONS+ STRICTUREPLASTY
operative findings: 1. multiple dense adhesions in distal ileal loops 2. stricture in
terminal ileum procedure: 1. general anesthesia given 2. patient scrubbed and
drapped from level of nipples above to groins below 3. midline incision given 4.
subcutaneous fat divided and linea alba reached and divided 5. poritoneum
incised and above findings noted 6. ileal adhesions released using sharp and blunt
dissection 7. stricture incised vertically and stitched transversely 8. leak and
patency checked 9. mesentric lymph node removed for histopathology 10.
peritoneal cavity washed with normal saline and suction done 11. rectus sheath
closed with prolene 1 12. subcutaneous fat closed with vicryl 2-0 and skin closed
with staples. 13. aseptic dressing done.

INCISIONAL HERNIA REPAIR

OPERATIVE FINDINGS: Incisional hernia with defect of almost 6cm. Contents of
sac: omentum PROCEDURE: 1)Abdomen scrubbed and drapped from the level of
nipples above to groin below. 2)Transverse supraumblical incision given. 3)Sharp
dissection through skin and subcutaneous tissue to underlying fascia done.
4)Hernia sac identified and opened and contents visualized. 5)5cm clearance of

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fascial defect done with careful finger sweep in sub fascial layer. 6)Primary repair
of fascial defect done with prolene 1 7)Retrorectus placement of prolene mesh
15x15cm done and stabilized with PDS 2/0 8)Radivac drain 16 fr placed and
secured with silk suture 9)Subcutaneous fat closed with vicryl 2/o 10)Skin closed
by subcuticular stitch with PDS 2/0 11)Aseptic dressing done 12)Patient woke up
and moved to recovery.

INGUINAL HERNIA REPAIR

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

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scrubbed and draped from level of nipples to umbilicus. 4. 5-6cm midline incision
given at level of selected gastrostomy site. 5. Subcutaneous fat and tissue
diathermized and peritoneal cavity entered. 6. Stomach identified and greater
curvature is pulled downward gently with babcock forceps until resistence is met.
7. Gastrostomy site is chosen on anterior gastric wall near greater curvature as
high as possible. 8. Two Purse string sutures placed with vicryl 0 at site chosen for
gastrostomy and left untied. 9. Gastrostomy is made at centre of purse string
using electrocautry. 10. Gastric contents aspirated with a sucker tube. 11. A stab
wound is made at previously marked exit site on abdominal wall and a clamp is
pushed from peritoneal cavity 2cm from midline incision to the abdominal wall.
12. Patency of balloon of foleys catheter checked. 13. 24 guage foleys catheter is
passed through abdominal stab wound and inserted into stomach through
gastrostomy. 14. Patency of gastrostomy checked with 30 ml N/S . 15. Purse string
sutures tied down and edges of stab wound pushed inwards. 16. Four sutures
with vicryl 0 are placed to secure stomach to abdominal wall. 17. After sutures are
placed , tube is pulled completely through abdominal wall apposing stomach to
abdominal wall’s underside and sutures are tied down. 18. External portion of
tube is anchored to skin with silk 1. 19. Abdomen closed with prolene 0 and skin
closed by subcuticular stitch with vicryl 3/0. 20. Aseptic dressing done.

POLYPECTOMY
OPERATIVE FINDINGS : WIDE BASED POLYP WITH SECONDARY HEMMORHOID AT
9 0 CLOCK PRIMARY HEMORRHOIDS AT 3 & 11 0 CLOCK PROCEDURE Genaral
anesthesia given patient placed in sim's lateral position perianal area scrubbed
with povidone iodine solution and drapped digital rectal examination done and
polyp delivered outside anal canal base of polyp ligated with vicryl and polyp
removed using electrocautry light dressing done and patient woke up and moved
to recovery.

SUBTOTAL THYROIDECTOMY

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

FISTULECTOMY + SETON PLACEMENT

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OPERATIVE FINDINGS: External opening at 4 0’ clock Internal opening at 3 0’ clock
Transphincteric fistula in ano PROCEDURE: 1. Spinal anesthesia given. 2. Patient
placed in lithotomy position. 3. Perianal area scrubbed with pyodine and drapped.
4. Digital rectal examination done to palpate the external and internal openings as
indurations felt b/w thumb and index finger, and to feel the tract of granulation
tissue. 5. Proctoscopic examination done to evaluate the anal canal and rectum
and identify the internal opening of the fistula. 6. Hydrogenperoxide injected
through external opening and bubbling from the internal opening into the anal
canal visualized. 7. Superficial part of the fistulous tract is excised using
diathermy. 8. A probe is gently inserted through external opening and taken out
through internal opening. 9. Piece of NG tube applied on the probe coming from
the internal opening and taken out through external opening. 10. Prolene (seton)
is passed through the NG tube and NG tube over seton removed. 11. Seton is
loosely tied. 12. The anal canal epithelium divided using electrocautry to the level
of internal opening. 13. A gauze dressing soaked with xylocaine jelly inserted in
the cavity of wound and secured with gauze dressing, sticking plaster and T
bandage. 14. Seton secured to the thigh.

PARTIAL GASTRECTOMY + ROUX EN Y RECONSTRUCTION

operative findings: tumor involving antral region of stomach procedure: 1.
general anesthesia given 2. abdomen scrubbed and drapped from level of nipples
to groin 3. vertical midline incision given skirting the umblicus 4. subcutaneous fat
diathermized down to linea alba, and linea alba divided in the midline with
diathermy 5. peritoneum lifted with forceps and then with artery forceps and
incised 6. peritoneal or visceral deposits searched 7. greater omentum lifted and
dissected from transverse colon 8. lymph nodes at the origin of left gastroepiploic
artery dissected out and the vessel doubly ligated and divided 9. subpyloric lymph
nodes dissected and right gastroepiploic vessels doubly ligated and divided 10.
distal stomach drawn caudally, transverse incision made in anterior leaf of lesser
omentum above the pylorus, suprapyloric lymph nodes dissected and right gastric
vessels doubly ligated and divided 11. 5-6cm of duodenum beyond the pylorus
mobilized 12. GIA used to transect the duodenum 13. left gastric vessels doubly
ligated and divided 14. stomach transected with a mechanical stapling device 15.

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specimen taken out and Roux en Y gastrojejunostomy done. 16. drains placed,
one at the operative area and one in pelvis 17. sheath closed with prolene 1,
subcutaneous fat closed with vicryl and skin closed with staples. 18. aseptic
dressing done.
EXCISION OF LEFT BREAST SWELLING
findings: mobile swelling in left breast at 2 0'clock position procedure: 1. general
anesthesia given and patient placed in supine position with left arm abducted 90
degree. 2. circumareolar incision given , flaps are raised on either side of incision
with electrocautry. 3. dissection done around the lesion in an attempt to
encompass the entire mass. 4. swelling excised, hemostasis secured and wound
irrigated with normal saline. 5. deep dermal skin layers closed with interrupted 3-
0 vicryl sutures skin approximated by vicryl rapid. aseptic dressing done.
TRIPLE BYPASS
operative findings: 1. superior mesentric vein and artery undissectable from
pancreas 2. whole pancreas involved in tumor 3. head of pancreas diffusely
adherent to posterior gastric wall and duodenum. procedure: 1. general
anesthesia given 2. patient scrubbed and drapped from level of nipples above to
groins below 3. midline incision given 4. subcutaneous fat divided and linea alba
reached and divided 5. poritoneum incised and above findings noted 6. jejunum
divided 2feet from dudenojejunal flexure 7. proximal stump taken to the stomach
and side to side anastomosed to greater curvature of stomach at 1 feet from
dudenojejunal flexure via GIA stapler(blue cartridge) 8. distal stump anastomosed
to gall bladder with vicryl 3-0 9. proximal stump anastomosed to jejunum at
3.5cm from dudenojejunal flexure, end to side anastomosis via GIA stapler(blue
cartridge) 10. mesentric lymph node removed for histopathology 11. peritoneal
cavity washed with normal saline 12. drains placed in subdiaphragmatic region,
morrison's pouch and pelvis 13. rectus sheath closed with prolene 1 14.
subcutaneous fat closed with vicryl 2-0 and skin closed with staples. 15. aseptic
dressing done

INCISION AND DRAINAGE OF PERIANAL ABSCESS

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OPERATIVE FINDINGS: a. 3*3cm perianal abcess at 5 0’clock position. b. Overlying
skin erythematous. c. No internal communication to anal canal. OPERATIVE
NOTES: 1. Spinal anesthesia given. 2. Digital rectal examination and proctoscopic
examination done to see any communication to anal canal. 3. Perianal area
scrubbed and draped. 4. Cruciate incision given at point of maximum fluctuation
with scalpel blade no.11. 5. Skin edges excised to deroof the abcess. 6. With a
finger in anorectum, cavity of abcess is carefully curetted. 7. Abcess cavity is
irrigated with hydrogen peroxide and normal saline. 8. Hemostasis secured. 9.
Cavity is lightly packed with gauze. 10. Aseptic dressing done. 11. Patient moved
to recovery.

EXCISION OF LIPOMA
OPERATIVE FINDINGS: A large encapsulated lipoma of about 10 * 8 cm size in
supraclavicular fossa abutting root of neck and external jugular vein. OPERATIVE
PROCEDURE: 1) General anesthesia given. Skin scrubbed and drapped on left side
of neck. 2) Elliptical incision given on lipoma 3) skin separated from lipoma using
scissors, diathermy and artery forceps as needed. 4) lipoma excised. 5)
hemostasis secured. 6) radivac drain of 12 no. placed and secured with silk suture
to the skin. 7) skin closed with subcuticular stitch with vicryl 2/0. 8) aseptic
dressing done.

BILATERAL INGUINAL HERNIA REPAIR WITH MESH (LICHTENSTEIN REPAIR)

Operative Findings: 1) Right Inguinal Hernia ( Direct) 2) Left Inguinal Hernia
(Direct) Operative Notes: 1) Spinal anesthesia given. The patient scrubbed and
draped from the umbilicus above to the pubic area below and the iliac spines
laterally. 2) Skin crease incision given on both sides with the landmarks being the
anterior superior iliac spine laterally and the pubic tubercle medially. The incision
is given one fingerbreadth above the midpoint of the inguinal ligament. 3) The
skin along with the fat and fascia opened up with securing hemostasis. External

15
oblique aponeurosis and superficial inguinal ring identified. External oblique
aponeurosis incised in the line of its fibers and structures beneath carefully
separated from its deep surface. 4) Ilioinguinal nerve identified and retracted
away from the area of dissection to avoid injury. 5) Swab on stick used to remove
the adherent fascia from the inguinal ligament inferiorly to the conjoint tendon
superiorly. 6) The spermatic cord lifted up using pubic tubercle 7) The spermatic
cord separated from the hernia sac and as both the hernia sacs are direct ,they
are not opened up and returned back with the plication of the posterior wall done
with Prolene 2/0 on either side. 8) Polypropylene mesh is then cut to a key hole
shape and sewn medially to the pubic tubercle with a 2cm overlap on the
tubercle, inferiorly to the edge of inguinal ligament and superiorly to the internal
oblique fascia bilaterally. 9) Internal ring is recreated by sewing together the two
tails of the mesh lateral to the cord bilaterally. 10) The external oblique
aponeurosis as well as the fat and fascia closed with Vicryl 2/0. 11) The skin closed
with Vicryl Rapid 3/0. 12) Aseptic dressing applied and moved to recovery.
LAPROSCOPIC CHOLECYSTECTOMY
Findings: 1)Thin flimsy adhesions over gallbladder 2)Gall Bladder filled with stones
3)Normal Calots triangle anatomy. Procedure: 1) General anesthesia given.
Patient scrubbed and draped from the epigastric area above to supra pubic area
below and mid axillary lines laterally. 2)Pneuperitoneum established via open
method. 10 mm infra umbilical incision given. Dissection done to directly visualize
linea alba and held with curved kockers forceps, incision given and stay sutures
taken with vicryl on J needle. Trocar inserted. Insufflation using CO2 and insertion
of camera done. 3) The patient is placed in reverse Trendelenburg position slightly
rotated to the left. 4) Placement of three other ports .One 10mm port in the
subxiphoid position with the intra-abdominal portion located to the right of
falciform ligament. A 5mm port 2 finger breadths below the costal margin and
close to midclavicular line. A 5mm port laterally along the anterior axillary line. A
laproscope is used to explore the abdomen for adhesions and potential injuries
that may have occurred during port placement. 5)A grasper is inserted through
the lateral 5mm to retract fundus of gall bladder towards diaphragm. Neck of gall
bladder is retracted towards right iliac fossa exposing calot’s triangle using the
middle 5mm port. thin flimsy adhesions released using maryland forcepswith
diathermy. 6)A hook cautery is used to carefully incise the peritoneum overlying

16
the calot’s triangle both anteriorly and posteriorly 7) All remaining connective
tissue is dissected out of calot’s triangle using blunt dissection and hook cautery
as needed. 8) Clips are then placed around the cystic duct – two below and one
above and one clip around the cystic artery is placed. 9) Scissors are then used to
cut the duct and hook diathermy used for cystic artery. 10) The gall bladder is
then dissected off the liver and a bag is used to remove it out of the abdomen
through the subxiphoid port. 11) Homeostasis secured. 12) The ports are removed
and gas stopped to remove free gas. 13) The linea alba defect is closed at the
umbilicus by tying the previously placed stay sutures and the subcutaneous tissue
and skin are closed with Vicryl rapid 3/0. 14) The rest of the ports are closed at
the skin only with staples. 15) Aseptic dressings are placed and the patient woken
up.
INCISIONAL HERNIA REPAIR
OPERATIVE FINDINGS: Two defects, 1 at the level of umbilicus, 1cm in size, 2nd to
the right of umbilicus 2cm in size. Contents of sac: omentum PROCEDURE:
1)Abdomen scrubbed and drapped from the level of nipples above to groin below.
2)Transverse supraumblical incision given. 3)Sharp dissection through skin and
subcutaneous tissue to underlying fascia done. 4)Hernia sacs identified , the two
hernial defects combined to form a single defect and sac opened and contents
visualized. 5)5cm clearance of fascial defect done with careful finger sweep in sub
fascial layer. 6)Primary repair of fascial defect done by doiuble breasting Mayo
repair with prolene 1 7)Retrorectus placement of prolene mesh 15*15cm done
and stabilized with PDS 2/0 8)Radivac drain 16 fr placed and secured with silk
suture 9)Subcutaneous fat closed with vicryl 2/o 10)Skin closed by subcuticular
stitch with PDS 2/0 11)Aseptic dressing done

PILODINAL SINUS
Patient presented via OPD with complaint of painless perianal discharge for 2
years.
On examination a small tender swelling of 2 x 2 cm cm seen at natal cleft with
thick hair around and surrroundng skin eythema.Patient was diagnosed with
pilonidal sinus.

17
Midline incision given , cavity layed opened. tract identified along with tuft of
hair. Wound kept open and packed with piodine dressing.Post op course was
smooth. Patient was discharged on 2POD on Tab Augmenten ,Tab novidat and
daily dressing with piodine.

ANAL FISSURE
Patient presented via OPD with complaint of painful defecation for 15 days.
On examination : Posterior anal fissure at 6 o clock position.
Patient was advised 0.2% GTN ointment ,stool softners and sitz bath for 6 weeks.
Patient followed in OPD. His did not resolved .Patient underwent lateral
sphinchterotomy ( ( closed method)under Spinal Anesthesia. Division of internal
sphinchter done in right lateral position by scalpel and confirmed by gloved
fingers.
Post operative course was smooth and patient was discharged on 1stPOD on stool
softners.

CORN EXCISION
patient presented via OPD with complaint of right foot painful lesion for 1 month.
EXAMINATION:
It was 2 x 2 cm tender with surrounding skin erythema.Patient was diagnosed
with corn.
PROCEEDURE:
AAA, xylocaine infiltrated around corn , incison made with scalpel around corn
and deepened with help of diathermy until corn excised. Hemostasis secured. ASD
done.

ANAL POLYP

18
Patient presented via OPD with complaint of painless bleeding PR for 2 month.

EXAMINATION:
on DRE 2 x 2 cm pedunculated mass felt.On proctoscopy a 2 x 2 cm pedunculated
mass seen.
Patient was diagnosed with anal polyp and advised colonoscopy and
polypectomy.

HEMORRHOIDECTOMY
Patient presented via OPD with complaint of painless bleeding PR for 2 months.
EXAMINATION:
Hemorrhoids at 3 ,7 and 11 O clock position o proctoscopy.

PROCEEDURE:

Spinal Anesthesia given.

Lithotomy position..
DRE performed.
Proctoscopy performed and hemorrhoids visualised at 3, 7 and 11 O clock
position.
Piles exposed by help of Dunhill forceps application at mucocutaneous junction.
Dissection done between internal and external sphinchter and continued till
pedicle.
Division of ligated pole mass leaving a good cuff of skin with final appearance of a
clover.
Piodone pack placed and aseptic dressing done.

19
TOTAL GASTRECTOMY

Operative findings: purulent fluid filled in peritoneal cavity, necrotic anterior wall
of stomach. No enlarged lymph nodes.

OPERATIVE STEPS: AAA, midline laparotomy incision given, skin, subcutaneous

tissue incised. Ligamentous teres ligated and divided. Falciform ligament ligated.
Whole abdomen explored. Above mentioned findings noted. Lesser omentum
opened and posterior wall of stomach and glass along celiac axis examined.
An opened is made in gastro colic ligament to the left of gastroepiploic arch.
Gastro colic ligament is clamped and ligated in section extending to the left up to
and including the main left gastroepiploic vessels and two short gastric arteries.
Main right gastroepipolic vessels divided and ligated near pylorus. Middle colic
vessels identified and saved. Right gastric vessel are clamped, divided and ligated
just above the duodenal bulb. Lesser omentum is divided proximally. Duodenum
is freed and divided just beyond pylorus between two clamped. Duodenum
stump is closed in two layers (first running over and over spiral suture, second
seromuscular interrupted suture) . Stomach mobilization is completed by dividing
lesser omentum up to diaphragm and dividing gastro phrenic ligament close to
diaphragm. Stomach is transected from the esophagus and stay sutures are taken
5 cm proximal to the line of transection. Roux en Y esophageojejunostomy is
made. Feeding jejunostomy made. Peritoneal cavity washed with 2 liters of warm
saline. Drains placed in pelvis, at duodenum stump and stomach bed. Rectus
sheath closed with prolene 0 continuous suture and secured with Aberdeen’s
knot. Fat closed with vicryl 2/0 interrupted suture. Skin approximated with
prolene 2/0 vertical mattress. Aseptic dressing done.

Patient discharged on 1ST POD on analgesics and antibiotics after pack removal.

20
 LYMPH NODE EXCISION
Patient presetned via OPD with hx of fever and cough for 1 week.

EXAMINATION:
multiple enlarged lymphnodes in anterior cervical trianagle, largest measuring 2 x
2 cm in postauricular area.

PROCEEDURE:
Excison of lymphnode under LA and sent for AFB smear and histhopath.

Patient discharged on Ist POD on analgesics and antibiotics.

ACUTE CHOLECYSTITIS
Patient presented via ER with epigastric and RHC pain for 12 hours.along with
anorexia and vomiting.

EXAMINATION:
Abdomen moving with respiration. Right hypochondrium tender.No rebound
tender.
.US Abdomen showed thick walled gallbladder with multiple stones.
Patient was diagnosed with acute cholecystitis and was managed conservatively
on NPO, analgesics, antibiotics and IV fluid therapy.
Patient recovered well. Pain and tenderness subsided.

21
Patient was discharged on 4th DOA and advised interval cholecystectomy after 6
weeks.

EMERGENCY APPENDECTOMY
OPERATIVE FINDINGS: ACUTE CATTARHAL APPENDICITIS
After all aseptic measures, Gridiron incision given . Skin subcutaneous tissues
incised. External oblique aponeurosis is cut n the line of incision. internal oblique
split in the line of fibers. Peritoneum grasped between two artery forceps,
pinched between thumb and fingers to check for any bowel presence. Peritoneum
cut in the line of incision. Tenia coli identified and followed till the base of
appendi. Index finger is hooked around base of appendix to deliever it from
wound. Mesoappendix ligated and divided in 2 to 3 bites till the base of
appendix. Appendicular base is crushed 5 mm away from caecum and is reapplied
5 mm away from initial site of crushing , ligated with vicryl 2/o at the site of first
crushing. Appendix is divided between suture and clamp. Exposed mucosa of
appendicular stump is mopped with piodine. Hemostasis secured. Peritoneum
closed with vicryl 2/0 continuous suture. Internal oblique closed with vicryl 2/ 0
interrupted suture. External oblique closed with vicryl 2/0 continuous suture. Fat
closed with vicryl 3/ 0 interrupted suture. Skin closed with prolene 2/0 vertical
mattress. Aseptic dressing done.

APPENDICULAR LUMP

20 yrs old male patient ,presented via ER with complaint of:

Right lower abdominal pain for 3 days.
Fever and vomiting for 1 day.
ON EXAMINATION:

22
Patient was lying supine on bed,looking anxious.He was febrile with fever of 101
F, tachycardiac with pulse of 105 bpm .Abdominal examination showed tender
illdefined lump of 8 x 8 cm in right iliac fossa .Guarding present.
Ultrasound abdomen showed an ill defined lump in right iliac fossa .
Patient was diagnosed with appendicular lump.
Patient was admitted,lump was marked and managed conservatively according to
OSCHNER SHERREN REGIEMN.
Patient was kept NPO, IV analgesics and antibiotics and 4 hourly monitoring of
pulse, temperature, lump size, lump tenderness and pain.
Patient’s fever settled. Pain subsided and lump decreased in size.
Patient tolerated sips on 3rd DOA which was progressed to full regular diet. He
was discharged on oral analgesics and antibiotics and planned for interval
appendectomy after 6 weeks.

ACUTE PANCREATITIS
patient presented via ER with epigastric pain and vomiting for 2 days. On
examination patient was anxious,tachycardiac. Abdomen was moving with
respiration. Tenderness was present in epigastrium. NO rebound tenderness.
Patients work up showed serum amylase 500. Diagnosis of acute pancreatitis was
made secondary to gallstones. Ranson score 3. on admission. Patient was
admitted for conservative management. Patient recovered well,pain subsided.
Patient was discharged on 3rd day of admission on oral analgesics and antibiotic.

BEDSORE
Patient is a case of multiple myeloma and bed bound for 2 months.He presented
in ER with complaint of multiple wound on his back. On examination second
degree bedsores present on sacrum. Patient was advised daily dressing with
pyodine,log turning 2hourly and treatment for medical illness.
LEFT GALACTOCELE

23
patient presented via ER with left breast painless engorgement for 2 months. She
did not breast feed her youngest kid who is 4 months of age. On examination left
breast was engorged, no skin changes and mildly tender. Ultrasound breast shows
left galactocele. She was advised to breast feed from left breast, milk expression
and breast pumping. Patient improved on conservative management.

HEPATICOPULMONARY FISTULA
Patient presented in ER with hiccups and productive cough for 15 days. He was a
diagnosed case of untreated hydrated cyst of Live. On examination patient was
anxious, tachycardiac and tachyapenic . Tender hepatomegaly of 7 cm below right
costal margins. CT scan is suggestive of liver abscess in right lobe of liver with
multiple daughter cysts mx 5x 5 cm and a hepatopulmonary fistula. Patient was
advised admission but they got lama due to financial constraints.

ANAL FISSURE(CONSERVATIVE MANAGEMENT)

Patient presented via OPD with complaint of bleeding PR for 1 month.On
examination anal fissure was present at 6 o clock position. She was advised GTN
ointment for L/A for 6 weeks and avoiding constipation.

FOURNIER’S GANGRENE
patient presented via opd with complaint of swelling on his perineum with
purulent discharge for 20 days. On examination an area of 10 x 10 cm of dead
necrotic tissue present over left hemiscrotum with purulent discharge. Patient
was diagnosed with fournier's gangrene and underwent wound debridement
under GA. Patient treated with IV antibiotics,
analgesics and daily dressing with EUSOL . He was discharged on 5th POD. Patient
was advised to continue with dressing with EUSOL once daily.

24
 INFECTED SEBACEOUS CYST
Patient presented via OPD with complaint of swelling at back for an year and now
with puerile not discharge for 10 days. On examination there was a 3x 3cm
swelling At the back with punctum and purulent discharge. It was soft,non
compressible,non fluctuant. Patient was diagnosed with infected sebaceous cyst
and underwent incision anddrainage under LA and 20 ml puss was drained.cavity
was left open and patient was advised daily dressing with pyodine and tablet
Augmentin 625 mg thrice daily for 5 days.

CORN EXCISION
patient preseted with hx of left foot swelling for 1 yr which got painful for 2
days.He was advised corn cap application and admission for excision of corns but
he refused and got lama.

SUBCUTANEOUS MASTECTOMY
25 yrs old male patient presented via OPD with complaint of :
Right sided painful breast enlargement for 4 months.
ON EXAMINATION: breast asymmentry R>L. no skin lesion or lump palpable.
Patient was diagnosed with right gynaecomastia and underwent Right
subcutaneous mastectomy under GA.
OPERATIVE PROCEEDURE: After all aseptic measures, 6 cm right subareolar
incision given along with lower margin of nipple areolar complex .Skin and
subcutaneous tissues incised. Superior and inferior flaps raised.Breast tissue
dissected uptil pectoralis major. Breast tissue removed enbloc . 14 Fr redivac

25
drain placed in cavity and secured with silk 2 0 . Hemostasis secured.Fat and skin
approximated with vicryl 2 0 simple interrupted and prolene 2 0 subcuticular
suture respectively. Aseptic dressing done.
OPERATIVE FINDINGS: Hypertrophied right breast disc.
Post operative course was smooth. Patient was discharged on 1st POD with oral
analgesics, antibiotics
and redivac drain.
SEBACEOUS CYST EXCISION

Patient presented via OPD with complaint of:

Swelling on back for 2 years.
Increase in size of swelling for 2 months.
ON EXAMINATION: 3 x 3 cm swelling on upper back, soft, non fluctuant, non
compressible,non tender, irreducible, transillumination absent, slip sign
absent.Overlying skin normal with a black spot in centre( punctum).
Patient was diagnosed with sebaceous cyst and underwent excision under LA.
OPERATIVE PROCEEDURE:After all aseptic measures, xylocaine with adrenaline
infiltrated around swelling . Elliptical incision given over swelling keeping punctum
in centre. Skin and subcutaneous tissue incised. Dissection done till walls of
sebaceous cyst. Cyst removed enbloc with its walls..Hemostasis secured. Fat
closed with vicryl 2 0 simple interrupted suture. Skin closed with prolene 2 0
vertical mattress suture. Aseptic dressing done. Patient was discharged on same
day on oral antibiotics and advised follow up in OPD.

ORTHOPEDICS SURGERY

26
 1. RIGHT BELOW KNEE AMPUTATION

OPERATIVE FINDINGS: diabetic foot with gangrenous necrosis of foot , loss of

peripheral pulses and sensory sensations.
OPERATIVE STEPS : Spinal anesthesia given. Patient lie supine. Torniquet to the
right thigh applied. Skin flaps marked. After all aseptic measures , anterior
incision given 10 cm below tibial tuberosity ,continued transversely round each
side of the leg to a point two third of the way down each side. Skin incision is
extended vertically and slightly anteriorly to a distance approx one and a half
times the length of transverse incision . Posterior flap is then completed with a
transverse flap at this level. The skin incision is deepened anteriorly down to deep
fascia. The anterior compartment muscles are divided at the same level as
anterior incision. Anterior tibial artery and vein are ligated and cut. Deep peroneal
nerve stump is made proximal to anterior incision. Incision is deepened till tibia
transversely and on the interosseous membrane. Tibia is divided with a Gigli’s
saw. Bevel the anterior half of the tibial stump with the saw and a rasp . lateral
compartment muscles are divided to expose fibula. Divide the fibula 1 cm
proximal and bevel the bone laterally. Deep posterior muscles of calf are divided
at the same level as fibula. Posterior tibial and peroneal vessels are ligated and
divided. Posterior tibial nerve divided distally. Soleus and gastrocnemius are
divided down to the end of the posterior flap . Both beveled medially and laterally
and excess skin trimmed to fashion a rounded stump. Torniquet released and
hemostasis secured.Redivac drain placed. Posterior flap is brought forward and
sutured anteriorly in layers. Figure of 8 dressing done.

RIGHT FEMUR INTERTROCHANTERIC FRACTURE

PROCEEDURE: Open reduction and internal fixation+ Dynamic hip screws
OPERATIVE STEPS: After all aseptic measures ,fracture reduced on traction table
by flexion, longitudinal traction, abduction and internal rotation. under image.

27
Incision given over right thigh proximal one third lateral aspect. Soft tissue
dissection done. guide wire is inserted in the neck and hammered till the head
under image. guide wire through the aiming device and advanced it into the
subchondral bone of the head, stopping 10 mm short of the joint. length of the
DHS screw with help of the measuring device is determined. Cannulated triple
reamer to the chosen length of the screw is adjusted. A hole for the screw and the
plate sleeve is drilled. screw is mounted on the handle and inserted over the
guide wire. four-hole DHS plate with the preoperatively determined CCD angle is
taken and slide over the guide wire and mate it correctly with the screw. plate to
the femoral shaft is fixed with plate holding cortical screws. Redivac drain placed
in the wound. Hemostasis secured. Wound closed in layers. Aseptic dressing
done.

INTER LOCKING NAIL RIGHT TIBIA

INDICATION : tibia mid shaft fracture
 OPERATIVE STEPS: After all aseptic measures , knee is flexed and mark
out inferior pole of patella ,borders of patellar tendon, joint line, tibial
tubercle. incision made from inferior pole of patella distally 2.5cm towards
tibial tubercle along medial 1/3 of patellar tendon. medial edge of patellar
tendon identifiec and incised patellar tendon retracted laterally and spread
down to guidewire starting point. Guide wire inserted just medial to the
lateral tibial spine on the AP radiograph, parallel with canal on AP view.
Fracture is reduced. Guidewire manually pushed past fracture site to distal
physeal scar. Checked with Carm imaging to ensure wire is in canal. nail
length measured with ruler.Reaming done and 35 cm nail inserted .
Proximal and distal interlocking screws placed and fixed. images of the
proximal, middle, and distal tibia is obtained. limb length, rotation,
alignment is checked and a knee ligamentous examination is performed.
Hemostasis secured. Saline irrigation done till clear back flow. patellar
tendon and paratenon layers closed with 0-Vicrylsubcutaneous layered
closure with 3-0 Vicryl done .skin closure with staples .Aseptic dressing
done.
28
COLLE’S FRACTURE REDUCTION by HAND SHAKING MANEOVER

After hematoma block , the hand grasped and traction applied in the
length of the bone with extension of the
wrist to disimpact the fragments. the distal fragment
then pushed into place by pressing on the dorsum
while manipulating the wrist into flexion, ulnar deviation
and pronation.Traction is maintained, a dorsal plaster slab is applied ,
extending from just below the elbow to the metacarpal necks and two-thirds of
the way round the circumference of the wrist. It is held in position by a
crepe bandage. Arm sling applied. Peripheral perfusion checked. Post reduction
xrays are obtained. patient advised analgesics and follow up in OPD after 2 days

ANTERIOR SHOULDER DISLOCATION

REDUCTION BY KOCHER’S METHOD

With Kocher’s method, the elbow is bent to 90°

and held close to the body; no traction should be
applied. The arm is slowly rotated 75 degrees laterally,
then the point of the elbow is lifted forwards, and
finally the arm is rotated medially. Arm sling applied. Post reduction xrays
obtained. Patient advised analgesics and follow up in OPD

29
DIABETIC FOOT
OPERATION: AMPUTATION OF LEFT BIG TOE
Findings: left big toe gangrene procedure: 1.spinal anesthesia given 2. after all
aseptic measures incision given along the demarcation between live and dead
skin 3. whole of dead and necrotic part excised 4. margins refreshed till bleeding
5. hemostasis secured 6. wound washed with pyodine, hydrogen peroxide and
normal saline 7. wound packed and aseptic dressing done

HUMERUS FRACTURE
Operation: open reduction and internal fixation with DCP
Findings: fracture of right humurus shaft Operative procedure: 1. After all aseptic
measures anterior vertical incision given 2. Subcutaneous tissue divided 3.
Fracture site approached 4. Fracture margins curetted and medullary canal
cleared of clots 5. 6 holes Dynamic Compression Plate (DCP) fixed with screws 6.
Hemostasis secured 7. Wound washed with normal saline and pyodine 8. Radivec
drain placed 9. Wound closed in layers 10. Aseptic dressing done

NEUROSURGERY

RIGHT FRONTOPARIETAL SPACE OCCUPYING LESION

30
operation: excision of right frontoparietal space occupying lesion
procedure: 1.AAA measures a right parietal curvilinear incision given just behind
coronal suture 2. flap raised and bone exposed 3. free flap of bone made by using
4 burr holes and then with the help of gigli saw 4. dura opened and brain needle
passed cautiously 5. cystic fluid collected and cavity explored 6. nodule reached
and excised 7. hemostasis secured and dura closed watertight 8. bone flap placed
and secured 9. wound closed in two layers 10. aseptic dressing done

HYDROCEPHALUS DUE TO TUBERCULOUS MENINGITIS

Operation : medium pressure VP shunt placement on R side
procedure: 1. AAA measures curvilinear incision given on R side around Keen's
point (3cm above and behind tragus) and flap raised 2. burr hole made at Keen's
point with Hudson's brace 3. subcutaneous tract made through passer from skull
to ant. abdominal wall till 2cm above the level of umblicus 4. peritoneal part of
catheter passed through subcutaneous tract 5. ventricular catheter passed with
stylet in right ventricle 6. CSF seen flowing freely 7. both catheters joined with
medium pressure chamber, flow checked and chamber fixed 8. peritoneal
catheter placed in peritoneum after a nick in rectus and then with help of trocar
9. abdominal incision closed in two layers with vicryl 10. skin of scalp flap closed
in two layers 11. aseptic dressing done.

Hydrocephalus
operation: medium pressure VP shunt placement on R side
procedure: 1. AAA measures curvilinear incision given on R side around Keen's
point (3cm above and behind tragus) and flap raised 2. burr hole made at Keen's
point with Hudson's brace 3. subcutaneous tract made through passer from skull
to ant. abdominal wall till 2cm above the level of umblicus 4. peritoneal part of
31
catheter passed through subcutaneous tract 5. ventricular catheter passed with
stylet 6. CSF seen flowing freely 7. both catheters joined with medium pressure
chamber, flow checked and chamber fixed 8. peritoneal catheter placed in
peritoneum after a nick in rectus and then with help of trocar 9. abdominal
incision closed in two layers with vicryl 10. skin of scalp flap closed in two layers
11. aseptic dressing done.

Femur exostosis
Operation: excision of exostosis
Findings: exostosis on distal medial side of femur Procedure: 1. After all aseptic
measures incision given on medial side of distal thigh over exostosis 2.
Subcutaneous tissue divided 3. Vastus medialis separated 4. Outgrowth on the
femur reached and excised with chisel and hammer 5. Bonewax used to secure
hemostasis 6. Wound closed in layers 7. Aseptic dressing done

POSTERIOR FOSSA MASS AND HYDROCEPHALUS

operation: VP shunt placement
procedure: 1. AAA measures curvilinear incision given on R side above Keen's
point (3cm above and behind tragus) and flap raised 2. burr hole made at Keen's
point with Hudson's brace 3. subcutaneous tract made with passer from skull to
ant. abdominal wall till 2cm above the level of umblicus 4. peritoneal part of
catheter passed through subcutaneous tract 5. ventricular catheter passed with
stylet 6. CSF seen flowing freely 7. both catheters joined with low profile medium
pressure chamber, ventricular part placed in elbow and flow checked and
chamber fixed 8. peritoneal catheter placed in peritoneum after a nick in rectus
and then with help of trocar 9.9abdominal incision closed in two layers with vicryl
10. skin of scalp flap closed in two layers 11. aseptic dressing don

L4/L5 SPINAL STENOSIS

32
Operation: spinal decompression (laminectomy and discectomy)
Findings: 1. Bilateral hypertrophied ligamentum flavum (L4-5) 2. Disc prolapse
(L4-5) Procedure: 1. General anesthesia given 2. Patient placed prone 3. Midline
incision given at level of L3,4,5 4. Fat and fascia diathermized 5. Hemostasis
secured 6. Subperiosteal dissection of erector spinae muscles done from the L4 &
5 lamina bilaterally 7. L4 Lamina removed bilaterally by Karrison’s punch 8.
Hypertrophied ligamentum flavum excised 9. Nerve roots retracted and prolapsed
disc between L 4 & 5 visualized and removed bilaterally 10. Hemostasis secured
11. Muscles and fascia closed with vicryl 12. Skin closed with silk 0 13. Aseptic
dressing done.

PROLAPSED INTERVERTEBRAL DISC L5/S1

Operation: spinal decompression (laminectomy and discectomy)

Findings: 1. Disc prolapse (L5/S1) 2. Hypertrophied ligamentum flavum
Procedure: 1. General anesthesia given 2. Patient placed prone 3. Midline incision
given at level of L5,S1 4. Fat and fascia diathermized 5. Hemostasis secured 6.
Subperiosteal dissection of erector spinae muscles done from the L5 S1 lamina 7.
L5 Lamina removed by Kerrison’s punch 8. Hypertrophied ligamentum flavum
excised 9. Nerve roots retracted and prolapsed disc between L 5 & S1 visualized
and removed 10. Hemostasis secured 11. Muscles and fascia closed with vicryl 12.
Skin closed with silk 0 13. Aseptic dressing done.

OBSTRUCTIVE HYDROCEPHALUS AND POSTERIOR FOSSA MASS

operation: VP shunt placement
procedure: 1. AAA measures curvilinear incision given on R side above Keen's
point (3cm above and behind tragus) and flap raised 2. burr hole made at Keen's
point with Hudson's brace 3. subcutaneous tract made through passer from skull
to ant. abdominal wall till level of umblicus 4. peritoneal part of catheter passed

33
through subcutaneous tract 5. ventricular catheter passed with stylet 6. CSF seen
flowing freely 7. both catheters joined with medium pressure chamber, flow
checked and chamber fixed 8. peritoneal catheter placed in peritoneum after a
nick in rectus and then with help of trocar 9. abdominal incision closed in two
layers with vicryl 10. skin of scalp flap closed in two layers 11. aseptic dressing
done

PEDIATRIC SURGERY

Right PPV
Operation: PPV ligation
Operative Findings: 1) patent processus vaginilis on right side Operative Notes: 1)
General anesthesia given. The patient scrubbed and draped from the umbilicus
above to the mid thighs involving the penis and scrotum and to the right anterior
superior iliac spine laterally. 2) Horizontal skin crease incision given about 1.5cm
long. 3) The skin along with the fat and fascia opened up with securing
hemostasis. External oblique aponeurosis and superficial inguinal ring identified.
4) External oblique aponeurosis incised in the line of its fibers and then split and
structures beneath carefully separated from its deep surface. 5) Swab on stick
used to remove the adherent fascia from the inguinal ligament inferiorly to the
conjoint tendon superiorly. 6) The spermatic cord lifted up and PPV, vas
deference and vessels identified 7) PPV ligated with vicryl 4/0 at the neck and
divided and and distal end left and testes returned to scrotal sac. 9) The external
oblique aponeurosis closed using a running continuous stitch in lateral to medial
direction and the fat and fascia closed with Vicryl 4/0. 10) The skin closed with
Vicryl 4/0 subcuticular. 11) Aseptic dressing applied and the patient woken up and
moved to recovery.

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 POST ELECTRIC BURN CONTRACTURE OF R LITTLE FINGER
operation: release + Z plasty + FTG
operative findings:
flexion contracture of right little finger procedure: 1. general anesthesia given 2.
patient's right hand and right inguinal region scrubbed and drapped 3. incision
given on contracture in Z shape using blade 15 4. flaps raised in subcutaneous
plane and contracture released 5. flaps sutured after transpositioning using 4/0
prolene interrupted 6. remaining central defect closed with full thickness graft
taken from right inguinal region 7. donor site closed primarily using prolene 4/0
interrupted stitches 8. splintage of right hand and aseptic dressing of hand and
right groin done 9. patient wokeup and moved to recovery.

PHYLLODE’S TUMOR
Operation: left sided simple mastectomy operative findings: 1. large tumor
occupying whole of the left breast Procedure: 1. General anesthesia given 2.
Patient placed supine with arm on the operative side extended on an arm board.
3. Position of lump and elliptical incision marked transversely encompassing
approximately 5cm of skin around the lesion and also the nipple. 4. Patient's left
side of chest and left arm scrubbed and drapped 5. elliptical incision given on
previously marked site. 6. Skin flaps raised in the plane between subcutaneous fat
and mammary fat. 7. Upper flap raised to the upper limit of breast i.e. 2-3cm
below the clavicle, approximately second intercostal space. 8. lower flap raised to
the lower limit of breast 9. breast tissue dissected down until the fascia of
pectoralis major. 10. 16french radivec drain inserted for flap and drain secured
with silk sutures. 11. Subcutaneous fat closed with vicryl interrupted and skin
closed with staples. 12. Aseptic dressing done.

INGUINAL ORHIDECTOMY

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OPERATIVE FINDINGS:
Thickened spermatic cord. 15 x 15 cm left testes. Whitish grey in color.
OPERATIVE STEPS: AAA, incision given on medial 2/5 of an imaginary line drawn
from pubic tubercle and ASIS. Subcutaneous tissue incised. External oblique
aponeurosis incised in the line of its fibers parallel to superficial ring. Spermatic
cord lifted at pubic tubercle. Ilioinguinal nerve identified and secured. Spermatic
cord double clamped at deep ring. Testes delivered into incision. Spermatic cord
cut and transfixed between the clamps. Hemostasis secured. External oblique
aponeurosis closed with vicryl 1/o continuous suture. 16 Fr redivac drain placed
and secured with silk 1/o. Fat closed with vicryl 1/0. Skin approximated with
prolene 2/0 vertical mattress . Aseptic dressing done.

PLASTIC SURGERY
1. EXCISON OF LESION
Case : lesion on left cheek for 5 years.
Proceedure : Excison under LA with 5 mm safe margins.

After all aseptic measures , inj 0.2 % Xylocaine injected around lesion.Skin and
subcutaneous tissue incised.lesion removed enbloc with 5 mm safe margins. V to
Y flap raised. Subcutaneous tissue closed with vicryl. Skin approximated with with
prolene 6 O. Aseptic dressing done.

2. RELEASE OF ECTROPION
Proceedure: After all aseptic measures upper lid burn margin analysed. Band of
scar pulling and everting upper lid identified. Xylocaine with adrenaline infiltrated
at proposed incision. Defect recreated. Split thickness skin graft harvested from
ipsilateral thigh applied on the raw area. Lower lid ectropion released. The raw

36
area covered with fullthickness skin graft harvested from ipsilateral groin. Aseptic
dressing done with tie over dressing.
3. DIAGNOSIS: DISTAL HYPOSPADIAS
Patient lie supine,Scrubbed from umbilicus till midthigh and drapped.Incision
marked including urethral plate and prepuce.Flaps raised and approximated over
14 Fr Foleys catheter with vicryl 6/0 in 2 layers.Tubulisation done. Dartos Fascia
approximated over it. Skin closed with vicryl 5/0. Aseptic dressing done.

4. BRACKA1
Patient lie supine.Scrubbed from umbilicus till midthigh and drapped. Incison
marked including urethral plate and prepuce. Raw area created around urethral
plate. SSG harvested from penile foreskin and placed over raw area.14 Fr Foleys
passed. Graft fixed with vicryl 5/0. Skin closed with vicryl 5/0 . Aseptic dressing
done.

5 .DIAGNOSIS: POST BURN CONTRACTURE ON RIGHT WRIST FLEXOR SURFACE

PROCEDURE: RELEASE OF CONTRACTURE AND SSG graft placement.
Patient lie supine. Right forearm scrubbed and drapped from elbow till fingers.
Fish mouth incision given over contracture. Skin subcutaneous tissue incised.
Contracture released. Split thickness graft harvested from right thigh via humbe’s
knife. Graft placed over raw area, secured via vicryl 5/0 .Tie over dressing done.
Splint applied. Donor area dressed with kartostat .Aseptic dressing done.

6. PROCEDURE: RELEASE OF POST BURN CONTRACTURE IN RIGHT AXILLA

AND FIVE FLAP PLASTY.

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 CLEFT PALATE REPAIR
DIAGNOSIS: Unilateral right cleft palate.
PROCEEDURE: Palatoplasty by Bardeck technique.
AAA measures, patient prepped and drapped.Xylocaine with adrenaline
infiltrated. Retractors placed. Markings made. Bilateral mucoperiosteal flaps
raised and pedicles identified. Flaps approximated and closure done in 3
layers.Hemostasis secured. Aseptic dressing done.

CLEFT LIP REPAIR

DIAGNOSIS: Unilateral right cleft lip
PROCEEDURE: UNILATERAL NORDHOFF REPAIR
AAA measures, markings made for the mode of repair, Xylocaine + 2 % adrenaline
infiltrated along with tattooing. Incision made. Flaps raised. Dissection done in 3
layers. Muscle , mucosa and vermillion separated. Hemostasis secured. Flap
approximated in 3 layers. Tajima and alar suturing done for the nose. Aseptic
dressing done.

OPEN RHINOPLASTY
DIAGNOSIS: CROOKED NOSE
AAA measures, markings made. Xylocaine+ adrenaline 2 % infiltrated. Incision
made. Cartilage graft harvested. Cartilage trimmed and the pocket made in the
nose. Wound and graft secured with a screw.Pack placed in nose. Hemostasis
secured. Aseptic dressing done.

OPEN RHINOPLASTY
After all aseptic measures, markings done. Xylocaine with adrenaline infiltrated.
Incision made at the columella and laterally dissection done. Cartilage exposed.

38
Cephalic trimming done. Intradermal and interdermal sutures made to refine the
tip. Lateral percutaneous osteotomy done to narrow the dorsum. Support with
cartilage provided to the dorsum of the nose. Hemostasis secured. Aseptic
dressing done. POP applied.

THORACIC SURGERY

FLEXIBLE BRONCHOSCOPY

INDICATION: productive cough, chest pain and weight loss

FINDINGS: Vocal cords normal.trachea mobile, carina sharp, right n left main
bronchus normal.All lobar bronchi normal. No lesion found.
PROCEEDURE: Broncho alveolar lavage

2. RIGHT POSTERIO LATERAL THORACOTOMY +ENUCLEATION OF CYST.

FINDINGS: 10 x 10 cm cyst in medial basal segment of right lung lobe. 450 ml
purulent fluid drained. Adhesion between right lung base and diaphragm, middle
lobe and chest wall.
PROCEEDURE: Patient lie supine and left lateral. Prepped and drapped.
Posteriolateral thoracotomy incision give. Latissimus dorsi fibers cut in the line of
fibers. Serratus anterior separated from its membranous attachment.Right lung
lobe identified.adhenolysis done. 10 x 10 cm cyst identified in medial basal
segement of right lung lobe. Cyst aspirated with 14 G cannula. 450 ml of fluid
aspirated. Cyst then removed enbloc. Air seal done by suturing all connections of
cyst with bronchi. Cavity washed with saline. Air leak checked and pneumostasis
secured. Hemostasis secured. 32 Fr chest drain placed posteriorly in pleural cavity
through a separated stab incision and connected to underwater seal. Ribs
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approximated via paracostal suture.Muscles and subcutaneous tissues
approximated in layers with continuous suture. Skin closed with prolene
subcutaneous sutures. Aseptic dressing done.

THORACOTOMY + DECORTICATION
INDICATION: EMPYEMA THORACIC
FINDINGS: crowded ribs
Frank puss filled in thoracic cavity
Thickened parietal pleura
1000 ml of slough removed.
Fissures fused
After all aseptic measures. Skin and subcutaneous tissue incised. Latissimus dorsi
fibers cut . Serratus anterior separated from its membranous part. Space created
between crowded ribs at 6 th intercostals space.Pleural cavity entered. Thickened
parietal pleura identified and stripped off. Slough removed manually.Adhesions
broken between the parietal pleura ,chest wall and diaphragm. Lung expanded.Air
leaks checked and closed.Hemostasis and pneumostasis done. 32 Fr chest drain
passed from separate incision anterior to mid axillary line and secured with silk
and attached to underwater seal. Paracostal Ribs approximated with paracostal
sutures.Muscles ,subcutaneous tissue closed in layer,continuous vicryl. Skin
closed with skin staplers. Aseptic dressing done.

TUBE THORACOSTOMY
INDICATION: pleural effusion
FINDINGS: Hemorrhagic pleural effusion of around 1 liter
PROCEDURE: After all aseptic measures, 2% lidocaine infiltrated in 5th
intercostals space in triangle of safety, anterior to mid axillary line.first skin is

40
anesthetized then needle is advanced to anesthetize the subcutaneous tissue and
pleura. 32 Fr chest tube is advance towards the diaphragm till 12 inch mark. Tube
clamped and attached to under water seal and secured with silk 1 interrupted
mattress suture. Air tight dressing done.

TUBE THORACOSTOMY
INDICATION: Pneumothorax
PROCEDURE: After all aseptic measures, 2% lidocaine infiltrated in 5th
intercostals space in triangle of safety, anterior to mid axillary line.first skin is
anesthetized then needle is advanced to anesthetize the subcutaneous tissue and
pleura. 28 Fr chest tube is advance towards the apex till 12 inch mark.Tube
clamped and attached to under water seal and secured with silk 1 interrupted
mattress suture. Air tight dressing done.

41