Right Hemi-Colectomy
SECTION 4.00 OPENING THE ABDOMEN
(Intro Next Page Previous Page)
4.01 POSITION
Supine.
Have access from nipples to knees.
4.02 INSERT A BLADDER CATHETER
Use a 16 French gauge rubber 2 way urethral catheter.
Use a full aseptic technique to insert the catheter.
Inflate the retaining balloon with 20ml sterile water.
Pull on the catheter until you feel the balloon held inside the bladder.
Connect the catheter to the connecting tube and the collection bag.
Hang the collecting bag over the far end of the operating table so that it will be visible to check the urine flow.
Check the connecting tube is slack to avoid tension on the patient's urethra.
Have the connecting tube secured to the end of the table using 25cm of 10cm wide Elastoplast with a mesentery around the tube.
This will avoid a full bag slipping down and pulling on the urethra.
Check urine is flowing into the bag.
Check the outflow tap on the bag is closed.
4.03 STANCE
Stand on the patient's right side with your one assistant opposite.
4.04 HAVE ANY STOMA BAGS REMOVED
4.05 HAVE ANY STOMA AND SURROUNDING SKIN CLEANED
Use 2 large Chlorhexidine soaked swabs.
4.06 CLEAN THE ABDOMINAL SKIN
Clean from the nipples to mid-thigh and from one iliac crest to the other.
Use 2 swabs on sticks with 0.5% Chlorhexidine in 10% Propanol and a third swab on a stick to dry off.
4.07 TOWEL UP
Use disposable drapes with adhesive edges.
Apply the side drapes first. This will prevent the adhesive sticking to the patient's intravenous lines, wiring and the operating table and cushions.
Place a medium skin towel horizontally on the skin on the level of the right iliac crest, centered on the patient's umbilicus.
Place a medium skin towel horizontally on the skin at the level of the left iliac crest, again centered on the umbilicus.
Place a large towel transversely over the lower half of the patient up to the symphysis.
Place a large towel transversely over the upper half of the patient down to the xiphisternum.
Rub the adhesive edges with a swab to ensure they are firmly attached to the skin.
4.08 SEAL OFF ANY STOMA
Stick an adhesive iodophore drape over the whole of the exposed abdominal skin, covering any stoma and extending onto the skin towels.
An extra large Steridrape is ideal.
4.09 CHECK THE DIATHERMY IS WORKING
Step on the pedal to hear a buzz from the diathermy machine at number 4 coagulation.
If there is no sound:
Check the diathermy pedal is present.
Check the diathermy lead is plugged into the diathermy machine.
Check the machine is adjusted to unipolar.
Check the diathermy machine is plugged in at the wall and is switched on.
Call a technician.
For more details see Diathermy pantogen.
4.10 CHECK THE SUCKER IS WORKING
i.e. A loud hiss.
Check the sucker tubing is pushed onto the sucker so tightly that no rings show on the sucker connector. This will prevent the tubing detaching at a critical moment.
4.11 CHOOSE THE INCISION SITE
The most convenient incision is in the midline. It is the ideal incision to perform on an unscarred abdomen.
This is quick to make and can be easily extended, as needed, to the above the xiphisternum or down to the pubis. It is quick to close.A right paramedian incision gives a somewhat better access to the right paracolic gutter than a midline incision of the same length. It is slower to make and to close. It will be nearer to a stoma than a midline incision increasing the risks of infection and incisional hernia. A healed wound may eventually be stronger than a midline incision.
Muscle splitting or transverse incisions have their advocates, but suffer from limitations of access and are more difficult and slow to open and close.
Reopening a previous incision is frequently required.
It raises the risks of damage to bowel, which may be very closely adherent to the back of the wound, or even herniating into the wound.
Go slowly and take great care.
Avoid making a new incision parallel to an incision which has been made within six months.
There is a real danger of the intervening abdominal wall necrosing.
The same applies to any incision crossing an old incision, where the centre of the wound may necrose.
4.12 SKIN INCISION - READ ON
4.13 INFILTRATE THE SKIN AT THE INCISION SITE
Use 20ml 0.25% Bupivacaine in a 20ml syringe with a green top 21SWG needle.
Check the needle is pushed onto the syringe so hard that it stops creaking.
4.14 FOR A PARAMEDIAN INCISION
GO TO STEP 4.22
4.15 MIDLINE INCISION - READ ON
4.16 EXCISE ANY PREVIOUS MIDLINE SCAR
Hold up each end of the scar with a Littlewoods forcep. The scar will stand out like a strand of tight cotton. This is the scar in the skin and in the superficial subcutaneous tissue.
Use a scalpel with a number 22 blade.
Make a cut in healthy skin along each side and around the ends of the scar.
Excise the scarred skin and subcutaneous tissue.
4.17 INCISING INTO NEW SKIN
Have the umbilicus held in a Littlewood forcep and retracted to the left by your assistant.
Use a scalpel with a no. 22 blade.
Identify the midline.
Cut from 2cm below the costal margin to 5cm above the pubis.
Cut around the right hand side of the umbilicus.
Beware of a symptomless umbilical or paraumbilical hernia.
4.18 CONTROL BLEEDING AS YOU GO
Capillary bleeding will stop in 5 -10 seconds.
Use coagulation with diathermy forceps for other vessels.
Diathermy needles are cannot squeeze vessels as they are coagulated.
The needles can cause stick injuries to operating staff.
4.19 DEEPEN THE INCISION
Apply traction to the skin to the right using a large abdominal pack.
Have your assistant apply counter traction to the skin to the left using another large abdominal pack. This will allow the wound to gape as you deepen the incision.
Use a new scalpel with a no. 22 blade.
Cut through the subcutaneous fat down to the linea alba. This is pinkish line rather than a white one. It is much tougher to the blade than the subcutaneous fat. The scalpel will cut through the linea alba, probably in the middle of the wound. You should see extraperitoneal fat bulging out through the opening.
If muscle bulges through the defect you have missed the linea alba in the midline and have opened the rectus sheath.
This will probably be the right rectus sheath, because your assistant is not applying as much counter traction as you are.
Increase your assistant's countertraction.
Incise the tissue further towards the left to find the linea alba.
If you still encounter muscle :
Dissect the muscle with dissecting scissors to identify its medial edge. This will be on either side of the muscle, depending which rectus muscle you have encountered.
Identify the linea alba, medial to the medial edge of the rectus muscle.
Open the linea alba.
Finish this step with the whole of the subcutaneous fat and linea alba opened up in the entire length of the wound. Make sure the opening in the linea alba is as long as the skin incision to provide maximum access for the rest of the operation.
If there has been an incision previously
Be prepared for : Suture material.
Use artery forceps and stitch scissors to pull out strands and knots.
Incisional hernia(s) containing omentum or bowel.
Dissect the contents free and reduce the hernias.
Be prepared to repair any such hernias at the end of the operation.
Old abscesses : Mop them out.
Take a bacteriological swab.
Collections of liquefied fat : Mop them out.
4.20 OPEN THE PERITONEUM
Choose a site in the middle of the opening in the linea alba for a new incision.
Choose a site at one end of the opening if adhesions are expected. This is where the chance of damaging bowel is somewhat less than in the middle.
Pick up extraperitoneal fat/ peritoneum between 2 artery forceps.
Incise the tissue longitudinally for 2cm Use a scalpel with its no.22 blade held flat.
The peritoneum should open and the intraabdominal tissues should fall back into the darkness of the peritoneal cavity.
If the peritoneum does not open
You may not be deep enough.
Pick up the tissues deeper in the opening using the artery forceps.
Reincise the tissue with the scalpel.
If the peritoneum still does not open
There may be adhesions beneath the peritoneum.
Look for the pinky brown colour of adherent bowel.
Slow down and go very carefully.
It may take an hour or more if there have been one or more previous operations.
Cut deeper with the flat of the scalpel blade once more.
Stretch open the tissues very carefully with dissecting scissors.
If there are dense adhesions and no sign of the peritoneal cavity
Consider making the opening at the other end of the wound.
Consider making a new incision in healthy skin.
Call a more experienced surgeon.
If you open the bowel (yellow bubbles of small bowel contents or brown faecal matter from large bowel)
Close the defect with continuous 2/0 Vicryl (Ethicon W9136).
Consider making the opening at the other end of the wound.
Consider making a new incision in healthy skin.
You are in serious trouble.
Call a more experienced surgeon.
4.21 ENLARGE THE PERITONEAL OPENING
Use dissecting scissors, with 2 artery forceps on the peritoneal edge.
Enlarge the opening to 5cm so that you can see whether there are adhesions.
If there are no adhesion:
Open up the peritoneum for the whole length of the wound.
Use dissecting scissors.
Start by cutting towards the xiphisternum. Have your assistant using a left forefinger in the peritoneal cavity as a retractor. He should be lifting and pulling towards the patient's left axilla to prevent his finger popping out of the wound.
Finish by cutting towards the pubis. Your assistant should use his right index finger as a retractor, pulling down towards the patient's left hip.
If there are filmy adhesions
Open the linea alba and peritoneum as much as you can under direct vision.
Sweep these adhesions away with gentle finger movements.
Clear the adhesions 5cm back from the peritoneal edge all round.
Use a Morris retractor to display any more adhesions.
Sweep away these adhesions or cut them with scissors to display the remainder of the inside of the planned opening in the peritoneum and linea alba.
Complete the opening of the peritoneum and linea alba using dissecting scissors.
If the tissues are too tough for the dissecting scissors
Use stitch scissors.
If there are dense adhesions
Go very slowly and carefully.
Use dissecting scissors to free the adhesions.
Have your assistant hold the edge of freed peritoneum and linea alba with artery forceps to put delicate countertraction on the adhesions.
Increase the length of the incision as you go.
Aim to free 5cm of the peritoneal surface of the whole wound.
This will enable you to insert a self-retaining retractor into the wound for a further inspection of the peritoneal cavity.GO TO STEP 4.35 PLACE 2 SKIN EDGE TOWELS
4.22 RIGHT PARAMEDIAN INCISION - READ ON
4.23 EXCISE ANY PREVIOUS RIGHT PARAMEDIAN SCAR
Hold up each end of the scar with a Littlewoods forcep. The scar will stand out like a strand of tight cotton. This is the scar in the skin and in the superficial subcutaneous tissue.
Use a scalpel with a number 22 blade.
Make a cut in healthy skin along each side and around the ends of the scar.
Excise the scarred skin and subcutaneous tissue.
4.24 INCISING NEW SKIN
Use a scalpel with a number 22 blade.
Make a skin incision 3 cms to the right of the mid-line, from 2cm below the costal margin, to 5cm above the pubic tubercle.
Move this incision medially to keep 2 cms of healthy skin between the incision and the edge of any stoma.
4.25 CLEAR FAT AWAY FROM THE RECTUS SHEATH
Use blunt dissection with a gauze swab.
The anterior rectus sheath usually shows up clearly with its vertically striped surface.
4.26 DEEPEN THE INCISION
Cut with a new scalpel through the fat and through the anterior rectus sheath along the whole length of the wound.
There will probably be two tendinous intersections in the rectus muscle IN in this exposure.
If there has been an incision previously:
Be prepared for : Suture material.
Use artery forceps and stitch scissors to pull out strands and knots.
Incisional hernia(s) containing omentum or bowel.
Dissect the contents free and reduce the hernias.
Be prepared to repair any such hernias at the end of the operation.
Old abscesses : Mop them out.
Take a bacteriological swab.
Collections of liquefied fat : Mop them out.
The tissues may be obscured by scarring.
Perform a rectus split by incising through the rectus muscle to the posterior rectus sheath and peritoneum.
4.27 COAGULATE BLEEDING VESSELS
Use diathermy forceps on bleeders in the fat and anterior rectus sheath.
4.28 PICK UP THE MEDIAL LEAF OF RECTUS SHEATH
Use 4 artery clips equally spaced down the wound.
4.29 FREE THE MEDIAL LEAF OF THE RECTUS SHEATH
Free the leaf from the rectus abdominus muscle.
Your assistant holds the lowermost two forceps up and apart.
Dissect the tissues with a scalpel in the right hand to cut and a diathermy forceps in the other to retract and coagulate.
Start at the bottom of the incision in the rectus sheath, and move steadily up to the top.
Slow down at the tendinous intersections in the rectus muscle because of blood vessels there. Coagulate the vessels before cutting them. Avoid detaching the muscle from the tendinous intersections.
If you do detach a muscle from the intersection:
Tuck the muscle inside the rectus sheath.
Take more care with the rest of the dissection.
Avoid making holes in the rectus sheath. Close any defects with interrupted 2/0 Vicryl (Ethicon W9136).
Stitch off obstinate bleeders in muscle with interrupted 2/0 Vicryl (Ethicon W9136).
4.30 EXPOSE THE POSTERIOR RECTUS SHEATH AND
EXTRAPERITONEAL FAT
Use a gauze swab to sweep the rectus muscle laterally off the posterior rectus sheath, and below this, off the extra peritoneal fat.
The posterior rectus sheath finishes 2-3cm below the umbilicus with a semilunar line. Below this level, there is only the extraperitoneal fat and peritoneum.
4.31 COAGULATE THE INFERIOR EPIGASTRIC ARTERY
AND VEIN
These vessels will be running cephalically, first on the extraperitoneal fat and then on the posterior rectus sheath. They will cross the line of incision into the peritoneal cavity.
Coagulate 2 sites on each vessels, medial and lateral to the planned opening of the peritoneum.
4.32 PICK UP THE PERITONEUM
Use two artery forceps in the middle of the wound.
Check, by pinching the peritoneum, that you have not picked up abdominal contents with the forceps. The 2 layers of peritoneum feel about 2mm thick. Omentum or bowel with the peritoneum make the tissues feel thicker than this.
4.33 OPEN THE PERITONEUM
Choose a site in the middle of the opening in the linea alba for a new incision.
Choose a site at one end of the opening if adhesions are expected. This is where the chance of damaging bowel is somewhat less than in the middle.
Pick up extraperitoneal fat/ peritoneum between 2 artery forceps.
Incise the tissue longitudinally for 2cm Use a scalpel with its no.22 blade held flat.
The peritoneum should open and the intraabdominal tissues should fall back into the darkness of the peritoneal cavity.
Be prepared to remove ascites with a sucker. Take a specimen for cytology, since the fluid may be simply inflammatory (or a transudate if there is obstruction.
If the peritoneum does not open
You may not be deep enough.
Pick up the tissues deeper in the opening using the artery forceps.
Reincise the tissue with the scalpel.
If the peritoneum still does not open
There may be adhesions beneath the peritoneum.
Look for the pinky brown colour of adherent bowel.
Slow down and go very carefully.
It may take an hour or more if there have been one or more previous operations.
Cut deeper with the flat of the scalpel blade once more.
Stretch open the tissues very carefully with dissecting scissors.
If there are dense adhesions and no sign of the peritoneal cavity
Consider making the opening at the other end of the wound.
Consider making a new incision in healthy skin.
Call a more experienced surgeon.
If you open the bowel (yellow bubbles of small bowel contents or brown faecal matter from large bowel)
Close the defect with continuous 2/0 Vicryl (Ethicon W9136)
Consider making the opening at the other end of the wound.
Consider making a new incision in healthy skin.
You are in serious trouble.
Call a more experienced surgeon.
4.34 ENLARGE THE PERITONEAL OPENING
Use dissecting scissors with 2 artery forceps on the peritoneal edge.
Enlarge the opening to 5cm so that you can see whether there are adhesions.
If there are no adhesions
Open up the peritoneum for the whole length of the wound.
Use dissecting scissors.
Start by cutting towards the xiphisternum. Have your assistant using a left forefinger in the peritoneal cavity as a retractor. He should be lifting and pulling towards the patient's left axilla to prevent his finger popping out of the wound.
Finish by cutting towards the pubis. Your assistant should use his right index finger as a retractor, pulling down towards the patient's left hip.
If there are filmy adhesions
Open the linea alba and peritoneum as much as you can under direct vision.
Sweep these adhesions away with gentle finger movements.
Clear the adhesions 5cm back from the peritoneal edge all round.
Use a Morris retractor to display any more adhesions.
Sweep away these adhesions or cut them with scissors to display the remainder of the inside of the planned opening in the peritoneum and posterior rectus sheath.
Complete the opening of the peritoneum and posterior rectus sheath using dissecting scissors.
If the tissues are too tough for the dissecting scissors:
Use stitch scissors.
If there are dense adhesions:
Go very slowly and carefully.
Use dissecting scissors to free the adhesions.
Have your assistant hold the edge of freed peritoneum and posterior rectus sheath with artery forceps to put delicate countertraction on the adhesions.
Increase the length of the incision as you go.
Aim to free 5cm Of the peritoneal surface of the whole wound.
This will enable you to insert a self-retaining retractor into the wound for a further inspection of the peritoneal cavity.
4.35 PLACE 2 SKIN EDGE TOWELS
These towels fold over the edge of the wound.
They keep the operation site neat and tidy.
They will reduce contamination of the wound by bowel organisms.
They will protect the wound edges from pressure effects of the self retaining retractors.
Place the 2 towels, folded 4 thickens, over the edges of the
wound and 5cms inside the peritoneal cavity. They need to extend the full length of the peritoneal opening.
4.36 FIX THE SKIN TOWELS
Use 2 towel clips at the ends of the wound to fix the towels to the skin.
Place a finger inside the end of the skin incision and lift up.
This will allow the skin clip to bite into the skin through the towel.
4.37 RETRACT THE WOUND EDGES
Use a large Finochietto retractor.
Place the winding mechanism facing your assistant.
Use 2 Finochietto retractors on a large wound.
Open the retractor with your assistant's hand under the winding mechanism. This will prevent skin drapes blocking the winding gears.
Check that bowel has not been nipped in the retaining arms of the retractor.
Additional retraction may be needed using a Morris or broad Kelly retractor to obtain a clear view of adhesions.
4.38 DIVIDE PERITONEAL ADHESIONS
Use dissecting scissors and finger dissection to get a clear view of the abdominal cavity and pelvis.
Ideally a complete view is needed. Previous surgery and dense adhesion formation may make this hazardous. Lack of access to the liver and pelvis may have to be accepted.