Right Hemi-Colectomy
DETAILED CONTENTS OF THE OPERATIVE SECTIONS
SECTION 1.00 OVERVIEW OF RIGHT HEMICOLECTOMY
2.01 FOR AN ELECTIVE PATIENT
2.02 FOR AN OBSTRUCTED PATIENT
3.01 CHECK YOU HAVE THE CORRECT PATIENT
3.02 CHECK YOU HAVE THE CORRECT SIDE
3.03 CHECK YOU HAVE A DIAGNOSIS
3.04 CHECK THE CONSENT
3.05 CHECK THE FUNCTION OF THE LEFT KIDNEY IS SATISFACTORY
3.06 CHECK THERE IS NO OTHER PROCEDURE TO DO
3.07 CHECK A DIATHERMY PAD IS ATTACHED TO ON THE RIGHT THIGH
3.08 CHECK A NASO-GASTRIC TUBE HAS BEEN INSERTED
3.09 CHECK THE PATIENT HAS HAD ANTIBIOTICS
3.10 ANAESTHESIA
SECTION 4.00 OPENING THE ABDOMEN
4.01 POSITION
4.02 INSERT A BLADDER CATHETER
4.03 STANCE
4.04 HAVE ANY STOMA BAGS REMOVED
4.05 HAVE ANY STOMA AND SURROUNDING SKIN CLEANED
4.06 CLEAN THE ABDOMINAL SKIN
4.07 TOWEL UP
4.08 SEAL OFF ANY STOMA
4.09 CHECK THE DIATHERMY IS WORKING
4.10 CHECK THE SUCKER IS WORKING
4.11 CHOOSE THE INCISION SITE
4.12 SKIN INCISION - READ ON
4.13 INFILTRATE THE SKIN AT THE INCISION SITE
4.14 FOR A PARAMEDIAN INCISION
4.15 MIDLINE INCISION - READ ON
4.16 EXCISE ANY PREVIOUS MIDLINE SCAR
4.17 INCISING INTO NEW SKIN
4.18 CONTROL BLEEDING AS YOU GO
4.19 DEEPEN THE INCISION
4.20. OPEN THE PERITONEUM
4.21 ENLARGE THE PERITONEAL OPENING
4.22 RIGHT PARAMEDIAN INCISION - READ ON
4.23 EXCISE ANY PREVIOUS RIGHT PARAMEDIAN SCAR
4.24. INCISING NEW SKIN
4.25 CLEAR FAT AWAY FROM THE RECTUS SHEATH
4.26 DEEPEN THE INCISION
4.27 COAGULATE BLEEDING VESSELS
4.28 PICK UP THE MEDIAL LEAF OF RECTUS SHEATH
4.29 FREE THE MEDIAL LEAF OF THE RECTUS SHEATH
4.30 EXPOSE THE POSTERIOR RECTUS SHEATH AND EXTRAPERITONEAL FAT
4.31 COAGULATE THE INFERIOR EPIGASTRIC ARTERY AND VEIN
4.32 PICK UP THE PERITONEUM
4.33 OPEN THE PERITONEUM
4.34 ENLARGE THE PERITONEAL OPENING
4.35 PLACE 2 SKIN EDGE TOWELS
4.36 FIX THE SKIN TOWELS
4.37 RETRACT THE WOUND EDGES
4.38 DIVIDE PERITONEAL ADHESIONS
SECTION 5.00 INSPECTING THE PERITONEAL CAVITY
5.01 INSPECT THE PERITONEAL CAVITY
5.02 ASSESSING THE TUMOUR - READ ON
5.03 CHECK THE PRESENCE OF A TUMOUR
5.04 CHECK THE SIZE
5.05 CHECK THE AMOUNT OF LOCAL SPREAD
5.06 CHECK THE MOBILITY OF THE TUMOUR
5.07 CHECK THE ADHERENCE TO LOCAL STRUCTURES
5.08 CHECK THE DEGREE OF OBSTRUCTION
5.09 CHECK FOR FAECAL LOADING PROXIMALLY AND DISTALLY
5.10 CHECK FOR LYMPH NODE SPREAD
5.11 CHECK FOR METASTASES
5.12 CHECK FOR LIVER METASTASES
5.13 CHECK FOR PERITONEAL AND OMENTAL METASTASES
5.14 CHECK FOR BOWEL METASTASES
5.15 CHECK FOR OTHER TUMOURS IN THE LARGE BOWEL
5.16 CHECK FOR SKIP LESIONS IN CONTENTS OF THE OPERATIVE SECTIONS ON CROHN'S DISEASE
5.17 CHECK FOR OVARIAN AND PELVIC METASTASES
5.18 CHECK FOR OTHER PATHOLOGY IN ABDOMEN AND PELVIS
5.19 CHECK FOR ADHESIONS OR HERNIAS AROUND ANY STOMA
SECTION 6.00 DECIDING ON RESECTABILITY
6.01 DECIDE ON RESECTABILITY
SECTION 7.00 MOBILISING THE RIGHT COLON AND ILEUM
7.01 IF THE TUMOUR HAS LIMITED EXTENSION INTO THE LATERAL PERITONEUM:
7.02 IF THE TUMOUR PENETRATES THE MUSCLE OF THE ABDOMINAL WALL:
7.03 IF THE TUMOUR IS ADHERENT TO SMALL BOWEL, OMENTUM, OR LARGE BOWEL:
7.04 IF THE TUMOUR IS FIRMLY FIXED TO LOCAL STRUCTURES:
7.05 A TRIAL OF MOBILISATION IS ACCEPTABLE BUT DO NOT GET CARRIED AWAY
7.06 MOBILISING THE RIGHT COLON AND TERMINAL ILEUM - READ ON
7.07 MOVE TO THE PATIENT'S LEFT
7.08 RETRACT THE RIGHT WOUND EDGE
7.09 PACK OFF THE SMALL BOWEL
7.10 DISSECT FREE ANY ILEOSTOMY
7.11 INCISE THE RIGHT PARACOLIC PERITONEUM DOWNWARDS
7.12 INCISE THE RIGHT PARACOLIC PERITONEUM UPWARDS
7.13 DISSECT THE LATERAL PERITONEUM
7.14 IDENTIFY THE RIGHT GONADAL VESSELS
7.15 TRACE THE RIGHT URETER
7.16 MOBILISE THE RIGHT COLON AND RIGHT MESOCOLON
7.17 MOBILISE THE HEPATIC FLEXURE OF THE COLON
7.18 CHECK THE MOBILISATION IS ADEQUATE
7.19 CHECK HAEMOSTASIS
7.20 PACK THE SPACE BEHIND THE FREED OFF BOWEL
7.21 RETURN TO THE RIGHT SIDE OF THE PATIENT
7.22 IDENTIFY THE MESENTERIC VESSELS
7.23 CHOOSE THE RESECTION SITE ON THE ILEUM
7.24 CHOOSE THE RESECTION SITE ON THE COLON
7.25 DIVIDING THE MESENTERY - READ ON
7.26 TURN TO THE PERITONEAL SIDE OF THE RIGHT MESOCOLON
7.27 SPREAD OUT THE RIGHT MESOCOLON
7.28 IDENTIFY A RIGHT MESENTERIC RESECTION LINE
7.29 DIVIDE THE MAIN VESSELS IN THE MESENTERY
7.30 DIVIDE THE RIGHT MESOCOLON
7.31 CHECK THE BOWEL ENDS WILL MEET EASILY
8.01 THE PRINCIPLES OF THE ANASTOMOSIS
8.02 THE PERFORMANCE OF THE ANASTOMOSIS
8.03 CLEAR THE TERMINAL ILEUM AT THE CHOSEN RESECTION SITE
8.04 CLEAR THE TRANSVERSE COLON AT THE CHOSEN RESECTION SITE
8.05 ASSESS PROGRESS
8.06 SURROUND WOUND WITH ANASTOMOSIS DRAPES
8.07 ISOLATE THE RIGHT COLON WITH 2 LARGE PACKS
8.08 CHECK THE PLANNED RESECTION LINES LOOK HEALTHY
8.09 CHECK THE PLANNED RESECTION SITES WILL COME TOGETHER WITHOUT TENSION
8.10 NON-CRUSH CLAMP THE TERMINAL ILEUM
8.11 NON-CRUSH CLAMP THE TRANSVERSE COLON
8.13 CRUSH CLAMP THE TRANSVERSE COLON
8.14 EMPTY THE BOWEL DISTAL TO TO THE ILEAL CLAMP
8.15 CRUSH CLAMP THE TERMINAL ILEUM
8.16 PREPARE TO DIVIDE THE ILEUM
8.12 EMPTY THE BOWEL PROXIMAL TO THE COLON CLAMP
8.17 HAVE YOUR ASSISTANT HOLD A SWAB ON A STICK UNDER THE ILEAL RESECTION LINE
8.18 CUT THE ILEUM FLUSH WITH THE PEYR'S CLAMP
8.19 HAVE YOUR ASSISTANT HOLD A SWAB ON A STICK UNDER THE COLON RESECTION LINE
8.20 CUT THE COLON FLUSH WITH THE PEYR'S CLAMP
8.21 REMOVE THE SPECIMEN
8.22 CHECK FOR BLEEDING FROM THE MESENTERY
8.23 PLACE THE 2 BOWEL ENDS SIDE BY SIDE
8.24 ISOLATE THE ILEUM AND COLON STOMAS FROM THE REST OF THE WOUND
8.25 CHOOSE THE METHOD OF ANASTOMOSIS
SECTION 9.00 THE ONE LAYER ANASTOMOSIS
9.01 START THE 1 LAYER ANASTOMOSIS
9.02 SETTLE THE POSITIONS OF THE BOWEL AND CLAMPS
9.03 CLEAN THE LUMEN OF EACH BOWEL END
9.04 CHECK THE CIRCUMFERENCES OF THE 2 BOWEL ENDS
9.05 THE PROCEDURE FOR THE 1 LAYER ANASTOMOSIS
9.06 INSERT THE FIRST OF THE ANASTOMOSIS SUTURES
9.07 INSERT THE NEXT ANASTOMOSIS SUTURES
9.08 REMOVE BOTH DOYEN'S CLAMPS
9.09 ADD EXTRA STITCHES AS NEEDED
9.10 CHECK THE LUMEN
9.11 EXAMINE THE BOWEL AND ANASTOMOSIS
9.12 GO TO STEP 11.01 CLOSE THE MESENTERIC DEFECT
SECTION 10.00 THE TWO LAYER ANASTOMOSIS
10.01 SETTLE THE POSITION OF THE BOWEL AND CLAMPS
10.02 CLEAN THE LUMEN OF EACH BOWEL END
10.03 CHECK THE CIRCUMFERENCES OF THE 2 BOWEL ENDS
10.04 THE PROCEDURE FOR THE TWO LAYER ANASTOMOSIS
10.05 INSERT THE FIRST OF THE OUTER SEROMUSCULAR SUTURES
10.06 INSERT THE SECOND OF THE OUTER SEROMUSCULAR SUTURES
10.07 PLACE INTERVENING INTERRUPTED SUTURES
10.08 START THE INNER LAYER
10.09 REMOVE BOTH DOYEN'S CLAMPS
10.10 START THE OUTER PART OF THE FRONT LAYER OF THE ANASTOMOSIS
10.11 ADD EXTRA STITCHES AS NEEDED
10.12 CHECK THE LUMEN
10.13 EXAMINE THE BOWEL AND ANASTOMOSIS
SECTION 11.00 PRECLOSURE PROCEDURE
11.01 CLOSE THE MESENTERIC DEFECT
11.02 CLOSE ANY LATERAL WALL DEFECT
11.03 CLOSE ANY ILEOSTOMY DEFECT
11.04 CHECK HAEMOSTASIS
11.05 CHECK THE POSITION OF THE NASO-GASTRIC TUBE IN THE STOMACH
11.06 CHOOSE A TUBE DRAIN
11.07 INCISE THE SKIN
11.08 DEEPEN THE INCISION
11.09 CATCH THE DRAIN IN THE ARTERY FORCEPS
11.10 PULL THE DRAIN INTO THE WOUND
11.11 CUT THE DRAIN TO FIT INTO THE PARACOLIC GUTTER
11.12 TUCK THE DRAIN INTO THE PARACOLIC GUTTER
11.13 CUT THE BEVEL OFF THE OUTER END OF THE DRAIN
11.14 STITCH THE DRAIN TO THE SKIN
11.15 CHECK THE SWAB, NEEDLE AND INSTRUMENT COUNTS
11.16 CLOSE THE WOUND FROM ANY EXCISED STOMA
11.07 CHECK THERE IS NO OTHER PROCEDURE TO DO
11.08 REMOVE ALL PACKS, SWABS, AND INSTRUMENTS FROM THE ABDOMENSECTION 12.00 CLOSING THE ABDOMEN
12.01 DECIDE ABOUT DEEP TENSION SUTURES
12.02 REMOVE THE FINOCHIETTO RETRACTOR
12.03 REMOVE SKIN EDGE TOWELS AND CLIPS
12.04 CHECK THE ABDOMEN IS FULLY RELAXED
12.05 PICK UP THE PERITONEUM
12.06 FOR CLOSURE WITHOUT DEEP TENSION SUTURES GO TO STEP 12.08 (CLOSE THE PERITONEUM)
12.07 FOR CLOSURE WITH DEEP TENSION SUTURES - READ ON
12.08 CLOSE THE PERITONEUM
12.09 CLOSE THE ANTERIOR RECTUS SHEATH
12.10 CHECK HAEMOSTASIS IN THE FAT
12.11 PUT 1G AMPICILLIN POWDER IN THE SUBCUTANEOUS FAT
12.12 CLOSE THE SUBCUTANEOUS FAT
12.13 CHECK THE SWAB, NEEDLE,AND INSTRUMENT COUNTS AGAIN
12.14 CHECK THERE IS NO OTHER PROCEDURE TO DO
12.15 CLOSE THE SKIN
12.16 TIE THE DEEP TENSION SUTURES
12.17 CLOSE ANY ILEOSTOMY WOUND
12.18 SPRAY THE WOUND
12.19 DRESS THE WOUND
12.20 CONNECT THE DRAIN TUBE
13.01 WRITE LEGIBLE OPERATION DETAILS
13.02 FILL IN THE AUDIT FORM
13.03 PRESCRIBE CALCIUM HEPARIN
13.04. ARRANGE A STEROID PROGRAMME
13.05 ARRANGE POSTOPERATIVE MEDICATION PROGRAMME
13.06. DICTATE A LETTER TO THE GENERAL PRACTITIONER AND REFERRING PHYSICIAN
SECTION 14.00 EQUIPMENT AND MATERIALS LIST