An M

a
i m ta
at ry
e
d Op
W
ig hite da era
ta t
ht
K
Lo n
Sh i
ve
ow

Breast
Operations
Hernias
operations
Abdominal
incisions
Appendectom
y
Cholecystect
omy
Splenectomy

Designed
Designed &
& Animated
Animated by:
by: Dr.
Dr. Hany
Hany

Dr.

Mohammed ElMatary

Lecturer of General Surgery

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Breast operations

Simple
Mastectomy
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Simple Mastectomy
Indications:
1-3rd & 4th stages of cancer breast.
2-acute mastitis carcinomatosis.
3-cystosarcoma philloides.

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Position

Body
Supine

:
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Position
Arm

&abducted & pronated (to avoid

brachial plexus injury)
: Extended

Axillary
vein
Lower
trunk

When arm is pronated

When arm is supine.

The incision :
Includes

Transverse elliptical incision

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INCISION :EXTENDS
Midline

Ant . axillary

2 Cm above
and below
the nipple

Procedure

Sternum

Clavicle

S.C fat
( micro
lobular)

Breast fat (macro

lobular)

Rectus
sheath
Ext
.oblique
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N.B. we should elevate the skin & S.c.

smoothly & as one unit -to -prevent
post-operative dimpling

Good

Bad
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Sweep off all breast tissue starting

medially to the axillary tail
Dissect Axillary tail
with your finger
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Medial perforators from

Internal mammary
vessels

Ligate medial perforators

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Types of breast surgery for

cancer breast

1-Extended radical
mastectomy:
Remove

-2 Skin:
-2 Breast:

Over the tumor

5 cm safety margin

Breast tissue
Breast nipple& areola
-2 Muscles:
Pectoralis major
Pectoralis minor
-2 F:
All fat
All fascia
-2 LN:
Internal mammary LN
Axillary LN

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Types of breast surgery for

cancer breast

2-Radical mastectomy:
Remove

-2 Skin:
-2 Breast:

Over the tumor

5 cm safety margin

Breast tissue
Breast nipple& areola
-2 Muscles:
Pectoralis major
Pectoralis minor
-2 F:
All fat
All fascia
-2 LN:
**********
Axillary LN

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Types of breast surgery for

cancer breast
3-Modified radical mastectomy:
Remove

-2 Skin:
-2 Breast:

Over the tumor

5 cm safety margin

Breast tissue
Breast nipple& areola
-2 Muscles:
**************
Pectoralis minor
-2 F:
All fat
All fascia
-2 LN:
**********
Axillary LN

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Types of breast surgery for

cancer breast

4-Simple
mastectomy&Sampling of
axilla:
Remove

-2 Skin:
-2 Breast:

Over the tumor

5 cm safety margin

Breast tissue
Breast nipple& areola
-2 Muscles:
*************
*************
-2 F:
All fat
All fascia
-2 LN:
**********

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Types of breast surgery for cancer

breast
5- Lymphectomy \
Quadrantectomy

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Modified radical
mastectomy
Pates operation
Indications:
1st &2nd Stage of breast cancer

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Clearance of Axilla:

Pectoralis
Major

Serratus
anterior
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Retract pectoralis major at lateral border to expose

pectoralis minor

Pectoralis
Major

Pectoralis
Minor
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DO
AX O
IL R O
LA F

Divide at origin (avascular)

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Welcome to
Axilla

Pectoralis minor
(cut)
Door of the axilla
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Sweep off the Axillary fat & L.N in downward

direction

Axillary fat & L.N

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Boundaries in dissection

Long thoracic nerve

Brachial
plexus

Axillary vein

Serratus anterior

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Separate the origin of pectoralis minor ,this will

make it free

Origin

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Complication Modified radical

mastectomy (Pates
operation)
1-Gangerene
2-The scar shape (cosmoses)
3-Bridle scar (the pt cannot abduct the arm)
4-Winging scapula (if long thoracic is
injured=C567 )
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Hernia
operations
:_
Indirect Inguinal Hernia
Herniotom

1-

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Herniotomy of indirect inguinal

hernia
Definition:
-Reduce the content +Excision of the sac.

Indications:
-In infants &children inguinal hernia

-Before herniorrhaphy in adults

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Groin
Incision
ise 3cm above the medial 2/3of the inguinal ligam
ASIS

Pubic
tubercle

3 cm

N.B.There is transverse type over the inguinal skin crease

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Groin
Incision

Skin

S.C tissue (Camper's fascia)

Scarpas fascia
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Procedure
Ligate & divide 3 superficial veins
which cross the inguinal ligament

Sup. Epigastric vein

Sup. Circumflex iliac vein

Sup. External pudendal vein

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Anatomy of the inguinal canal

Roof : lower arching fibers of
int. oblique & transverus abd.

Ant. Wall:
Ext. oblique
apponeurosis
& fleshy
fibers of int.
oblique

Post. wall:
Fascia
transversalis
.

Conjoint
tendon.

Floor : upper surface of

inguinal ligament

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Divide external oblique

apponeurosis in the direction of
its fibers from external ring to
internal ring

Internal
ring

External
ring
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Reflection of external oblique & identify the

ilioinguinal nerve

Ilio inguinal nerve

N.B. its injury causes hypothesia over the scrotum

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Separate the cord from posterior w

of the canal

Conjoint
tendon

Cord
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Internal ring

Divide
cremastric m.&
internal
spermatic fascia

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Internal ring

Dissect the sac

Inferior epigastric vessels medial

neck

Sac

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N.B.There sac is pearly white in color &anteromedial

to the vas.

Criteria of the neck of the

sac : Narrowest part of the sac.

Inferior
epigastric a.
medial to it.

Extra-peritoneal collar of
fat

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Open the fundus of the sac

Internal ring

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Reduce the content

The content

Internal
ring
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what is transfixation ?

The first knot

Ligate half the length then full length

to the other side.
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Finally we do Transfixation

&
excision of the sac

Is done

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2-Herniorrhaphy

of indirect inguinal hernia

Def:
Close the defect in the weak canal by suturing

Indications:
It is the standard operation in adult hernia

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Types of repair in
herniorrhaphy
1-Sholdices repair=3 double breasting
2-Bassini's repair
Disadvantages:

-Failure of shuttering mechanism

-Bad healing
3-Marcy repair
4-Halshted repair:
Disadvantages:

-The cord is covered with skin only

(liable to trauma sterility)
-It is done only for old age
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What is the double

breasting ?
First row

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Complete the second row & ligate it

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Shouldice's repair = 3 double

breasting

Extra peritoneal fat

Fascia transversalis incised along

the length

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DOUBLE BREASTING of
the fascia transversalis
behind the cord

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Second row is done

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Second row is done

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Double breasting the conjoint tendon to inguinal

ligament behind the cord

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Closure of external oblique by double breasting

in front of the cord

First row

Second row WhiteKni

Bassinis repair

Narrowing of the
internal ring from
medial side

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Conjoint tendon sutured to inguinal

ligament by interrupted sutures

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Closure of external oblique aponeurosis in one

layer in front of the cord.

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Halshted repair

Divide external oblique apponurosis in the direction

of its fibers from external ring to internal ring
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Suture the external oblique m.

behind the cord

N.B. it done only in the old age

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Hernioplasty
D a r n in g

G r a ft in g

N a tu ra l

S y n t h e t ic

P r o le n e

M e c a lie
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Hernioplasty
Indications:
1-Very weak abdominal wall
2-Large defect
3-Recurrent hernia

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Hernioplasty
Technique:
A-Tension free mesh:

(Lichtenstein)
B-Mesh plug technique:
(for small
hernia)
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Tension free mesh ( Lechtenstein)

Mesh

Inguinal ligament.

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Mesh plug technique (for small

hernia)

Mesh
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Direct Inguinal Hernia

Invagination of the sac:
We Invaginate the sac followed by Hernioplasty =
Tension free mesh

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1-expose till peritoneum

2- identify the hernial sac after removal of extra
peritoneal fat
Fascia
transversalis

The cord

The sac
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3- apply purse string suture

around the sac .

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4-invaginate the sac & ligate the

purse string suture .

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Repair of the direct hernia and apply

mesh.

the

Mesh

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Femoral

Hernia

Incision
s
High approach
incision

ASI
S

3/5
medial

Pubic
tubercleLow approach incision

Low approach Procedure

Skin

S.C fat

Inguinal lig.
Femoral vein

Expose the sac till the

neck
Pectineal lig.
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Abnormal obturator artery behind

lacunar lig.

Abnormal
obturator artery

If the defect is narrow we have to cut the lacunar

lig. This will injury the abnormal obturator
artery

Open the fundus of the sac

Reduce the content

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Transfix the sac as high

as possible & divide it

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Repair
Place N-shaped suture
between Pectineal ligament
and inguinal ligament

Excised sac

Protect femoral
vein by retractor
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High approach Procedure

Retract the skin

above and below
the inguinal lig.

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Then we do longitudinal
incision in the ext. oblique
apponeurosis along its fibers.

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Divide fascia transversalis

from lateral to medial

Displace the cord

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The cord

The sac behind the

inguinal lig. & come
from the femoral
defect

pe
ri
to
ne
um

Inguinal lig.

Scarpas
fascia

Retracted
Fascia
transversalis.

The sac enter

through the
femoral ring

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Elevate the sac upward

Inguinal
ligament.

Femoral defect

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Open the sac

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Reduce the content

Retracted fascia
transversalis

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Transfix the sac &

divide it.
Retracted fascia
transversalis

Repair the femoral defect by

ligation of the inguinal ligament
into the Pectineal ligament

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Then we close the fascia

transversalis

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Finally we close the Ext. oblique

apponeurosis

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McAvady
As high approach but from medial
side
Disadvantages:
Injury to nerve supply of the Rectus muscle
because it comes from the lateral side

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technique

Lower paramedium incision

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The Rectus muscle which will be

retracted from lateral to medial.
Retraction of the
Rectus muscle
from lateral to
medial

peritoneum
Ant.
Rectus
sheath

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Para umbilical hernia

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Para umbilical hernia

& Semilunar incision
above it

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Para umbilical hernia

& Semilunar incision
below it

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Transverse elliptical
incision in the umbilical
hernia

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Para umbilical hernia

Incisions:

Semilunar above
it

Transverse elliptical incision

Semilunar below it
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Rectus sheath

sac

Dissect the neck of the sac from all

directions

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Open the sac at its neck

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Content :
omentum
Rectus
sheath

sac

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Reduce the
content & excision
of the sac.

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After reduction of the sac we repair the defect

in the linea alba after convert the rounded
defect into elliptical form

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Para umbilical hernia

A-Mayo's repair
B-Anatomical repair

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Mayo
s rep

ai r

Double breasting with mattress

sutures & the upper flap become over
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the lower one

Anatomical repair

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Anatomical repair
The defect

The linea is wide &

redundant
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Suture the linea alba including the defect

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Umbilical hernia for children

As Mayos repair
NB:
We must do subumbilical incision not
supraumbilical because it leaves an ugly
scar

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Incisional hernia
Anatomical repair

Elliptical
incision

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Keel repair

FIRST THERE IS A DEFECT

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Then hernia occurs through this defect

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We Invaginate the sac.

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Finally We close the defect.

Fibrin threads

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Keel repair
Disadvantages:
-Bad healing (so:use prolene
sutures)
-There may be adhesions between
the sac&contents (intestinal
obstruction)

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Anatomical Repair

First identify the scar edge

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2- refresh the scar edges by excise

it.

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3- suture the muscles in separate

layers.

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Abdominal incisions
1-Midline incision.
2-Paramedian incision (Transrectal or not):
Upper Paramedian
Lower Paramedian
3-Subcostal incision:
If in Rt side = Kocher incision.
4-Grid-iron incision.
5-Lanz incision.
6-Pfannesteil incision. = Transverse lower abdominal
incision.

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Midline incision
Advantages:
-Rapid
-Exploratory
-less bleeding

Disadvantages:
-Weakening of linea alba----bad
healing, hernia
-Bad cosmoses
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Midline Incision

Notice the
curve around
the umbilicus.

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Midline Incision
Skin

Peritoneu
m
Trans.

Int.

Ext. obl.

Paramedian incision
Advantages:
-Low incidence of Incisional hernia
-Exploratory

Disadvantages:

-Time consuming

- More bleeding

Disadvantages of Transrectal incision:

-the medial part becomes devitalized due
to cutting of both nerve&blood supply

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Upper paramedian incision

Sub-costal margin

Just below the umbilicus

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Lower Para median

Incisions

Just above the

umbililcus

Till the pelvis

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Paramedian Incision

Skin

Ext.
Oblique
Int.
Oblique
Trans.
Abdominus

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Transrectal Incision

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Transrectal Incision

Skin
Ext.
Oblique
Int.
Oblique
Trans.
Abdominus

Sub-costal incision
Indications of Kocher incision:
-Sure diagnosis of chronic calcular
cholecystitis with no other
associated lesions (as Saints or
Wilkies triad)
-Wide subcostal angel

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Subcostal Incisions

Kocher Incision
The Rt. Side only

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Subcostal Incision
M

1. Ant. Rectus sheath.

2. Rectus muscle.
3. Post. Rectus sheath.

1. Ext. oblique
2. Int. oblique
3. Trans.
abdominus

Skin
T.A

Int.O

Ext.O

Subcostal incision
Advantages:

-More cosmetic
-The liver supports the incision if
in the Rt side
-Direct access (eg:to gallbladder)

Disadvantages:

-More bleeding
-Injury to 8,9,10th nerves
-Time consuming
-Not exploratory
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Grid-iron incision
Mcburney s
point

2
3

umbilicus

1
3
ASIS

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Split External Oblique Apponeurosis in line of

its fibers

Int. obl.
Trans. abd

Split Int. Oblique and Trans. Abdominus

with blunt artery forceps

Peel the peritoneum from the trasversus

abdomens
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Hold the peritoneum with the forceps

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Examine peritoneum from

any underlying structures

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Elevate the peritoneum with non toothed

forceps & incise the peritoneum

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Allow access of air by a small incision

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Grid-Iron Incision
Skin

Internal
obli.

Superficial
fascia

External obli

Cutting of Ext. oblique In the same direction

of muscle fibers
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Grid-Iron Incision
Advantages:
hernia

-Muscle splitting decreases

incidence of Incisional

Disadvantages:
-Direct hernia due to injury of
the ilioinguinal nerve

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Lanz Incision

Pfannesteil

Pfannesteil Incision
1-skin incision
2- Anterior
Rectus sheath
3-Rectus
abdominus
muscle
Skin & s.c.
tissue
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After retraction of the two recti

peritoneum will appear

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Lanz incision
Indications:
children)

-Done when cosmoses is highly

indicated (eg:in

Advantages:
-More cosmetic

Disadvantages:
-difficult access
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Appendicectomy

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Appendicectomy
Indications :

1-Acute non-complicated appendicitis

2-Recurrent sub acute appendicitis
3-After resolution of appendicular mass by 3 ms
4-After drainage of appendicular abscess by 6 ms
5-Appendicular tumor (Argentafin cell tumor)

Contraindications :

1-Appendicular mass
2-Appendicular abcess
3-Crohns disease affecting the coecum

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Incisions

Rt. Para median

Grid-iron

Lanz
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Procedure
Identify the coecum
- Has taenia Coli.
- Blind.
- Faint blue
- Fixed in its place.

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Identify the
appendix

Tinea coli
converge
toward
the
appendix

Appendix

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Allis
forceps

Appendicular
artery

Hold the appendix by 2 Allis forceps

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Artery
forceps

Mesoappendix

Place artery forceps across

Ligate the vessels &then

divide the mesoappendix

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Place purse-string in the base of the coecum

2 cm of
appendix
In coli

Horizontal manner

Kocher
forceps

2nd to squeeze

1st to ligature

the pus

3rd

not to drop the pus

Apply kocher forceps 3 times on the base of

appendix
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Ligate & divide the appendix between

the 1st & 3rd crushing sites

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Leave the Kocher forceps in 3rd time not to

drop the pus

2
3

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Paint the stump with alcohol

The stump

Alcohol
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Invaginate the stump & tie the purse string around it.

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Problems
1-The appendix is not inflamed:
We should do appendectomy although normal appendix to avoid it
again in DD of pain in Rt iliac fossa:
-Rt tubo-ovarian pathology
-Inflamed Meckels diverticulum's
-Perforated peptic ulcer
-Chrons disease
2-The appendicular base is markedly inflamed:..Omit
crushing
3-The coecum is inflamed (tephlitis): ..Omit purse string
suture
4-The coecum is gangrenous
Small part..remove the gangrenous part
Large partlimited rt hemicolectomy
5-If the iliac fossa is empty =Sub hepatic appendixmuscle
cutting
6-If the tip of the appendix is not visible = Retro cecal
appendix

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Inflamed Meckls
diverticulum's

Localized resection and close in longitudinal

manner

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The Coecum is Gangrenous

Small part =
remove

Large part = Rt. hemicolecto

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Empty iliac fossa

Sub hepatic appendix

Muscle cutting incision

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Subhepatic
appendix

Anterior abd. Wall

ms.

Muscle cutting

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The tip of the appendix is not

accessible
Apply 2 artery forceps at the
base through a window in
mesoappendix

Retrocecal
appendix

window
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Piece meal
cutting

Purse-string
suture
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Complications of appenicectomy
Early:
1-Hge
2-Infection: peritonitis,wound,pelvic or subphrenic
abscess
3-Paralytic ileus
4-Portal pyemia
5-Fecal fistula

Late:
Adhesions (small intesten)
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Gall bladder
operations

Cholecystectomy
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ghtLove

Cholecystectomy
Indications:
1-Chronic calcular cholecystitis
2-Acute calcular cholecystitis:
-During 1st 48 hrs with experienced surgeon
-3 Weeks after resolution of the acute attack
3-Chronic non calcular cholecystitis after failure of the medical
treatment &the gall bladder is non functioning
4-Empyema & mucocele of the gall bladder
5-Torsion,traumatic perforation,tumors
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Position
X-ray device

Supine . on X-ray table

Elevate
Rt. hypochondrium

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Common bile duct

Liver

Vertebra

Elevate Rt. hypochondrium

15
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Without elevation

With elevation

Incisi
ons

Kocher incision

Rt. Para median

We do muscle cutting in
the ant. Abd. wall

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Procedure

Introduce your hand between the liver and the diaphragm to

displace the liver downwards that brings the gall bladder in the
center of the field

Widen the field

The liver

Gall
bladder
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Incise the peritoneum over the free part of lesser

omentum

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Dissection of triangle of Callot.

LIVER
CHD
C .D

Formed of :CHD-Cystic D.Liver

CA

Formed of :CHD-Cystic D.Cystic artery

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LIGATE AND DIVIDE CYSTIC ARTERY

Cystic artery
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The Catter pillar anomally

Enlarged,
dilated
tortuous Rt.
Hepatic art.

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GB
Cannulate it & do
intraoperative
cholangiogram

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Divide the duct & leave small

stump

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Dissect the gallbladder from hepatic bed by the

cautary

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THEN REMOVE THE GALL BLADDER

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CHOLEDOCOLITHOTOM
Y
&
EXPLORATION OF C B
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D
ightLove

Choledocolithotomy &
Exploration of CBD
Indications:
-Preoperative:

1-History of jaundice
2-Abnormal liver function ( increase alkaline
phosphatase)
3-Charcots triad (Pain,Fever,Jaundice)
4-Dilated CBD or CBD stones demonstrated by
U\s,ERCP,PTC

-Intraoperative:

1-Dilated CBD>12 mm
2-Palpation of the stone in CBD
3-Multiple small stones in GB

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Liver
GB
CBD
Pylorus

Pancreatic
duct

Duodenum
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Normaly the CBD has flattened lumen ,so any

direct incision will injure the posterior wall.

CBD
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So we should first take 2 stay sutures in the anterior wall

of the CBD

Liver

CB
D

GB

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Second step is to incise the ant. Wall of the

CBD.

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Remove the stone by stone

forceps
Stone forceps

GB

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Remove the stone by stone

forceps

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Now we insert the Choledocoscope in CBD

to avoid missed stones.

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Now we will insert T-tube after making its

lumen incomplete circle, Why?

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Then we Place T-Tube & inject dye, close over it

if there is no available intra-operative
cholangiography.

CBD

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Closure over the T-tube.

10

N.B. Removal of the tube is done after

days after formation of fibrous
tract.

Complications of
Choledocolithotomy
1-Intraoperative:
Accidental ligation of the CBD or hepatic artery

2-Preoperative:
-Early
-Biliary leak
-Wound infection,septicemia
-Jaundice,retained stone
-Late
- Biliary stricture

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Spleen
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Normal spleen
anatomy

Ant.lienorenal
lig

Gastrosplenic
lig.

Stomac
h
Pancreas

Splee
n

Kidne
y
Post.lienorenal lig.

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Gastro-splenic
ligament

Anterior
lienorenal
ligament

Spleen
Pancreas

posterior lienorenal ligament

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splenectomy
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incisions

Mid-line incisionLeft subcostal

incision

Upper paramedian incision

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Left sub-costal incision

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After muscle cutting of the ant.abd. wall

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Down displacement of the spleen to

become in the field.

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Push spleen medially to insert

hot packs

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Insert hot packs to avoid

reposition of spleen

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Stomach
(medially)

Spleen
(medially)

Hot packs

Divide the
posterior layer of
lienorenal ligament
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Divide the posterior layer of

lienorenal ligament

Traction of the
spleen medially
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Division of posterior layer of lieno- renal ligament

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Divide the gastro-splenic

ligament

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Division of the gastrosplenic

ligament

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Divide the anterior layer of the

lienorenal ligament

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Now we will see the vascular

pedicle

Post. lienorenal lig.

Pancreas

Splenic artery

Ant.
Lienorenal lig.
GastroSplenic
ligament
Spleen
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Ligate and divide the splenic art.

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Second step is to squeeze the

spleen before division of splenic
vein.

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Now divide splenic v. and remove

spleen.

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Problems

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Multiple splenic
adhesions

We ligate
the
vascular
pedicle
and allow
auto
infarction
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 ...
...
Dr. :Mohammed

El-

Matary
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