GIT sx principles 1 - blood supply + tissue handling

Halsteads principles of surgery

Gentle tissue handling

Haemostasis

Preserve blood supply

Asepsis

Minimal tension

Accurate tissue apposition

Obliterate dead space

Purpose of large enough incision

Allow exploration, easier sx, reduce tissue trauma

Instrument to handle gut

Hands, stay sutures

Instrument to cut gut

Scalpel → scalpel, metzenbaum scissor

Issue with panc handling + eelctrocautery

Pancreatitis

Issue with excessive gut handling

Ileus

Midline coeliotomy initial incision

Xyphoid → (2/3 umbilicus → pubis)

Duodenal dam manoeuvre (colon for L abd)

Pull duo ven + L to move everything in abd to L → view R abd

What to assess for organs in ex lap

Size, shape, position, consistency, surface, colour

Instrument shown

Balfour Retractor

Instrument shown

Suction unit

Instrument shown (for gut handling)

Debakey thumb forceps

Instrument shown + purpsoe (Can use allis tissue)

Doyen bowel forceps → occlude bowel

Order to assess structures in ex coeliotomy

1 - parenchymatous organs (liver, spleen, panc, R kidney+adrenal, L kidney+adrenal)

2- GIT (stomach, duo, colon, caecum, ileum, jejunum, mesenteric LN)

3- urogenital

4- specific to problem

Methods to stop H

Ligature

Electrocautery

Whe. To not use electrocautery

Gas filled organs

Least vascular location of stomach

Halfway between greater + lesser curvature

Least vascular location of SI

Antimesenteric border

Least vascular location of Ileum

2/3 between mesentric to antimesenteric border

Least vascular location of Oeseophagus

Sections running along

Partial colonectomy ligation (A→A)

Small BV branches from main colic a

Subtotal colonectomy ligation (B→B)

Ligate at circles

Total colonectomy ligation (C→C) ileocolic anastomoses

Ligate at crosses

Issue with liver hamostasis

Coagulopathies in hepatopathy

Vascular

Pringle manoeuvre

Temp occlude hep blood flow for 15min By clamping coeliac a + portal v

Liver biopsy homeostasis options

Guillotine method - crush BV + bile ducts together → cut dist to lig

Loops overlap through parenchyma → cut section out

Finger fracture technique - score through parenchyma → expose BV + ducts → ligate → cut → repeat until end

Pancreas biopsy homeostasis options

Guillotine technique

Blunt dissect + individual ligation

Limited electrocautery

Options for cutting intestine + best one

A- antimesenteric > mesenteric → less perfusion

B- antimesenteric = mesenteric → good perfusion

C- antimesenteric < mesenteric → best perfusion

How to assess intestinal viability

Colour - bright pink

Arterial pulses - small BV

Ongoing peristalsis

Oesophageal blood supply

Segmental + collateral submucosal plexus

Why is maintaining blood around pylorus important

Coeliac a maintains other organs (gastric, gastroepiploic, hepatic, cr pancreaticoduodenal, splenic)

Jejunum + ileum blood supply preservation

Submucosal plexus - dec rough handling

Mesenteric BV - lig location

Ligate BV to remove → colour change

Colon + rectum blood supply preservation

Ligate small branching BV