By J. Riordian. Edgewood College.
The skin loss after excision of scar or growth can suitably be made good by this type of skin graft cheap 60 caps ayurslim amex. Granulating wound is unsuitable for this type of skin graft due to the presence of some sort of infection in the wound order 60 caps ayurslim with mastercard. Full thickness skin is best taken from locations where the skin is thin such as postauricular area buy generic ayurslim 60 caps online, supraclavicular area and eyelids or where skin is loose and redundant such as flexor creases of the elbow, buttock and groin. A very important point in technique is that the graft is lifted gently with a skin hook and removed from the subcutaneous tissue by sharp dissection. The graft should be carefully fixed with accurate skin sutures to the recipient site as vascularisation occurs through the edge as well as from the deep surface. The recipient wound should be mapped on a metal-foil and the donor area is accordingly sized. The incision is now made vertically straight down through the full thickness of the skin along the mapped margin, underlying fatty tissue should be excluded. The edge of the skin is now retracted by stay sutures with fine silk to avoid trauma to the skin edge by the use of such instrument like dissecting forceps. The graft is now applied to the recipient wound and fixed to its periphery with fine silk stitches. Short stab wound may be made if the graft is a large one to prevent collection of fluids in between the graft and the wound. Finally, pressure bandage should always be applied and the part is kept immobilized. The skin margins of the donor area are undermined and approximated by silk sutures. Due to cosmetic reason its use is being taken over by the patch graft, as it leaves a stippled surface when it heals. The grafts are then transferred to the recipient raw area in rows about 1/4 inch apart to cover the entire surface. Pedicle flaps, which include subcutaneous fat as well as skin, provide padding that prevents ulceration and so are useful for wounds such as decubitus ulcers and those that sustain frequent trauma. The graft in the form of a flap is first created by making skin and subcutaneous incisions along 3 sides, leaving intact the side with the best blood supply. The flap is undermined and then is sutured immediately to the closeby recipient site or may be delayed i. The donor site may be closed by primary suturing or is covered with a split thickness skin graft. These can be of three types — (i) a direct pedicle graft, (ii) bridge pedicle graft and (iii) tube pedicle graft. That means skin from the trunk can be used to cover wounds of the upper limb, skin of the lower limb can be used to cover wounds of the other lower limb (crossJimb flap ). These two parts are always kept approximated by firm bandaging or by plaster of Paris. The flap actually consists of two parts — (a) the part for actual graft and (b) the part which connects the recipient area to the donor area (the pedicle). The latter part is responsible for nutrition of the former and it should be broad enough to carry the blood supply to the flap. The bed from where the flap is raised should be covered with the surrounding skin by undermining. After three weeks when the flap is supposed to have established its nourishment from the recipient area, the pedicle is divided. The flap is raised and the raw wound beneath the flap is closed by approximating the adjoining skin margins. Then the recipient part is pushed beneath the bridge and the edges of the bridge flap are sutured to the recipient area with fine silk. As the risk of infection is less and the blood supply is very much assured this graft is more preferable to the conventional whole thickness skin graft. Stage I consists of raising the flap, which is attached at both ends and stitching the sides of the flap to form a tube. The skin and superficial fatty layer up to being used to repair a defect of Use cheek. After one week that end is completely severed, the end is opened up and grafted to the recipient area. The last few years have seen the development of a new understanding of the blood supply of the skin and how it may be harnessed. The blood supply to the skin ends with vertically running arterioles to the undersurface of the dermis and up into the papillae. In some areas of the body, arteries accompanied by veins run for considerable distances in the subcutaneous tissues which can be called axial vessels. Examples of this are the superficial temporal, occipital and superficial inferior epigastric vessels. In certain areas of the body vessels run vertically through the subcutaneous fat from the deep fascia. In these places inclusion of deep fascia into a cutaneous flap allows greater Fig. The rich blood supply to muscle is mainly from one source, so that the muscle with the overlying skin can be lifted and swung on a pedicle. A large area of the skin overlying the muscle can be lifted with the lattissimus dorsi muscle. The flap of the muscle with the overlying skin can be rotated and pivoted on these vessels. This flap has been used for closure of the chest wall defects and defects in the neck. The pectoralis major is detached both from its origin and insertion keeping a 5 mm of vertical strip of muscle overlying the acromiothoracic trunk. The island of skin, the muscle mass and the vessels are swung on an axis just below the clavicle and can reach the neck, cheek and even inside of the mouth. The skin defect of the chest is closed by undermining edges or by application of a skin graft. The flap is dissected to incorporate the vessels from the 2nd, 3rd and 4th costal spaces. The lower margin of the flap is along the axillary fold, where the skin is extensile and long flap can be constructed. Careful dissection below the fascia covering pectoralis major muscle is undertaken without damaging the perforating vessels. This flap may be transferred to be used in the neck, face, inside of the mouth and even to reconstruct the pharynx and upper oesophagus. These vessels run 2 cm below and parallel to the inguinal ligament towards laterally almost in a straight line. The flap is raised with a margin of 3 cm on either side of these vessels and can extend outwards over the iliac crest. The deep fascia is included with the skin upto the sartorius muscle after which this vessel perforates the deep fascia and care must be taken not to damage these vessels. This graft has been used as contour- forming operation in the breast, but did not succeed much.
When the involved bowel is viable order ayurslim overnight, it should be pushed into the peritoneal cavity buy line ayurslim. The sac is ligated at the neck and excised and the operation is concluded as herniorrhaphy as described above generic ayurslim 60caps fast delivery. If the condition of the patient permits and if the bowel above the strangulation is not much distended, resection and end-to-end anastomosis should be performed then and there. If on the contrary the general condition of the patient is poor and the anaesthetist is disagreeable and the bowel above the strangulation is grossly distended, it is better to exteriorize the bowel. Femoral hernia is the 3rd according to frequency, after inguinal and incisional hemia. It is normally closed2 by the femoral septum, which is nothing but thickened extraperitoneal tissue. Behind by the pectineus muscle covered by its fascia and the pectineal ligament of Cooper, a thickened band running along the iliopcctineal line. Sometimes the pubic branch of the inferior epigastric artery takes the place of the obturator artery and is known as abnormal obturator artery. This artery often curves round the medial margin of the femoral ring and is liable to be injured while cutting the medial margin of the lacunar ligament to relieve the strangulated femoral hernia. Femoral canal is the innermost compartment of the 3 compartments of the femoral sheath. The middle compartment of this sheath carries the femoral vein, while the outer compartment carries the femoral artery. The femoral canal contains areolar tissue, fat, lymphatic vessels and the lymph node of Cloquet. The anterior layer is the prolongation downwards of the fascia transversalis behind the inguinal ligament and in front of the femoral vessels. The posterior layer is the downward prolongation of the fascia iliaca behind the femoral vessels. Posteriorly, the femoral sheath rests on the pectineus and adductor longus muscles medi ally and the psoas major and iliacus muscles laterally. The saphenous opening (or fossa ovalis) is an opening in the fascia lata situated 4 cm below and lateral to the pubic tubercle. The upper and outer margins of the saphenous opening are thickened and sharp — known as falciform process. This process turns the femoral hernia upwards once it has come out of the saphenous opening. The saphenous opening is covered by loose areolar tissue called a cribriform fascia. The fascia of scarpa, the membranous layer of the superficial fascia of the abdomen is attached to the fascia lata just below the saphenous opening. After this it progresses upwards in the subcuta neous tissue of the thigh and may even reach above the inguinal ligament. A fully distended femoral hernia assumes the shape of a retort with its bulbous extremity looking upwards. The tendency of the femoral hernia to move upwards after it has come out of the saphenous opening is attributed to the following factors : (a) Firm unyielding falciform pro cess turns the hernia upwards. Though majority of the femoral herniae pass through the femoral canal, a few rare types may be seen as below : 1. Remember that even in females the commonest hernia in the groin is the inguinal hernia. In fact a small femoral hemia may be unnoticed by the patients for years till it get strangulated. It is usually a small globular swelling situated below and lateral to the pubic tubercle. In case of strangulation patient suddenly gets pain at the local site which immediately spreads allover the abdomen with vomiting. In this case one may follow the tendon of adductor longus upwards to reach the pubic tubercle. If they become large thery adopt a size of a retort in which the bulbous portion looks upwards and may reach above the inguinal ligament. But these signs are relatively less reliable in case of femoral hemia due to (i) adherence of the contents and (ii) narrowness of the neck of the sac. When impulse is felt on the index finger it is the indirect inguinal hemia, when on the middle finger it is direct inguinal hemia and when on the ring finger it is the femoral hemia. The neck of the hemial sac lies below the inguinal ligament and lateral to the pubic tubercle, whereas an inguinal hemia is always above the inguinal ligament and medial to the pubic tubercle. The reasons are mainly two: (i) there is always a risk of strangulation, (ii) no truss can be fitted to control femoral hemia as it becomes displaced with the flexion of the thigh. High operation of McEvedy’s operation — approach is made mainly above the inguinal canal but also below it. Lockwood operation — the approach is below the inguinal ligament via a groin-crease incision. A vertical incision is made over the femoral canal extending upwards above the inguinal ligament for about 3 inches. This part of the incision is deepened, the anterior2 rectus sheath is incised and the rectus muscle is retracted medially. The fascia transversalis is divided and by working downwards the sac entering the femoral canal is identified. In irreducible or strangulated hernia, the lower part of the incision is deepened first till the fundus of the sac is reached. The sac is then opened, its contents are dealt with, after which the upper part of the incision is deepened in the similar way as has been described earlier and the neck of the sac is drawn upwards through the canal and ligatured. The repair is now effected by suturing the conjoined tendon with the ligament of Cooper. The incision is made similar to that used for inguinal hemia, except for the fact that it is placed nearer to the inguinal ligament. This incision should not be extended laterally upto the midinguinal point to avoid injury to the in ferior epigastric vessels. The inferior margin of the wound is also retracted downwards and the extra-peritoneal fat is pushed aside by gauze to expose the hernial sac entering the femoral canal. If the sac is empty and is not adherent to the surround ing structures, it should be drawn up, the neck is ligatured and the rest of the sac is ex - cised. Sometimes the sac remains adherent and the urinary bladder may adhere to the medial side of the sac. To dear the fundus of the sac properly, the lower margin of the wound has to be retracted downwards.
In the beginning the wall of this saccule is formed by all the coats of the bladder generic ayurslim 60caps visa, but as the sac enlarges purchase 60 caps ayurslim otc, the muscle becomes thinned out over the fundus and may eventually disappear purchase cheap ayurslim on line. Such infection usually persists and even if it is cured by suitable antibiotics, there is every chance for reinfection to occur. When diverticulum is present for a long time, peridiverticulitis may occur and lead to adhesions between the diverticulum and the surrounding structures. In majority of cases the calculus lies within the bladder, though in a few cases calculus is seen within the diverticulum (Fig. Occasionally a dumb-bell shaped calculus may be seen which fills the diverticulum and protrudes into the bladder. The first one is from the urinary bladder and the second from the diverticulum — first specimen is clear, whereas the second specimen is cloudy due to presence of infection. Symptoms of complications such as those of presence of a vesical calculus or those of hydronephrosis and infections of the kidney may be noticed in a few cases. Cystography may detect the presence of diverticulum by showing a project on outside the bladder. First the bladder is emptied of unne and then a radio-opaque dye is introduced through the catheter. Radiographs are taken before and after micturition to show the position of the diverticulum and its capacity. The clear cut hole of the diverticulum which is usually of a diamater of a Lead Pencil is very clearly seen through cystoscopy. If the bladder is not distended enough, the opening of the diverticulum may be closed. In this case the radiating pleats of the mucous membrane is seen from a point which is the orifice of the diverticulum. So it is the rule to get the bladder fully distended before cystoscopy is performed for search of diverticulum. The bladder should be well irrigated before cystoscopy is performed so that the infected cloudy urine is cleared off to get a clear view of the inside of the bladder. Sometimes an expert can pass a cystoscopy into the diverticulum and examine the interior of the diverticulum to exclude any neoplasm there. First cystoscopy is performed and a large ureteric catheter is passed through the ureteric orifice on the affected side and left in situ. A midline suprapubic incision is made and is deepened till the anterior wall of the bladder is reached. Before incising the bladder, the peritoneum is dissected upwards from the superior surface of the bladder till the diverticulum is reached. Now the diverticulum is cleared from the surrounding structures by sharp and blunt dissection. Once the whole of the inside of the diverticulum is packed with the strip of gauze, it is now easy to complete the freeing process of the diverticulum from surrounding structures from the outside of the bladder. Once the whole of the diverticulum has been freed and the neck is clearly felt to be free from surrounding structures particularly the ureter, the neck of the diverticulum is cut from its attachment to the bladder from outside with a diathermy knife. After the diverticulum has been separated the strip of gauze is removed and the resulting opening of the diverticulum is closed by two layers. The cystostomy incision is sutured around a Malecot catheter and the abdominal wall is closed leaving a corrugated drain in the retropubic space. Sometimes the diverticulum is densely adherent to the surrounding structures so that it cannot be freed by dissection. In this case the neck of the diverticulum is cleared and the ureter is kept safe out of the diverticulum. The neck is now cut with diathermy knife so that the diverticulum now becomes separated from the bladder. A separate corrugated drain is placed close to the diverticulum and left there for 2 or 3 days. If there is any enlarged prostate or bladder neck contracture as the cause of urethral obstruction to cause such diverticulum, prostatectomy or operation for bladder neck contracture is performed at the same time as diverticulum. About 1 to 2% of inguinal or femoral hemiae contain such diverticu lum of the bladder. This condition is relatively more frequently seen in femoral hemia and in direct inguinal hemia. Malignant tumours — (i) Transitional cell carcinoma — either de novo or secondary to papilloma. Sometimes carcinoma of the pelvic colon or rectum first presents with symptoms of cystitis and cystoscopy reveals an area intense inflammation which is the first site involved by the carcinomatous lesion. It is an established fact that prolonged exposure to certain carcinogens is associated with a high incidence of vesical neoplasm. Recent work suggests that the multiple transitional cell tumours involving the urinary tract e. Whatever may be the chemical nature of these carcinogens, a few industries have been incriminated to cause bladder tumours and that bladder tumours are now considered as occupational hazards. The industries responsible are dyeing industry, rubber and cable industries, certain types of plastic industry, printing industry, leather industry etc. These amines are metabolised to orthoaminophenols by the liver and conjugated there with sulphate or glucuronic acid and then excreted through the kidneys. These materials are attacked in the urine by Beta- glucuronidase, which hydrolyses to form orthophenols which are liberated. These orthophenols are found in increased concentration in the urine of patients who are having vesical tumours. There is evidence that the activity of urinary Beta-glucuronidase is increased by the presence of vesical infection, in presence of other cancers, renal infection, urolithiasis, renal cyst and benign enlargement of the prostate. It has been recently shown that in smokers there is increase in carcinogenic metabolites of tryptophan excreted in the urine. There is also increased urinary excretion of products with the orthoaminophenol structure in persons who are chain smokers. It has been suggested that cigarette smoking contrib utes directly to the origin of bladder cancer. On cessation of smokings the levels of carcinogens excreted in the urine return to normal. There is evidence that the activity of urinary Beta-glucuronidase is also increased in schistosomiasis infestation. The villi may spring directly from a small circumscribed area of the mucosa or may arise from a well defined pedicle. In case of the former the villi are longer, fragile and delicate and looks like sea-anemone with delicate tentacles moving with the flow of urine. In these villi there are connective tissue stroma which are exceedingly delicate and vascular consisting largely of capillary loops.
The upper end of the pilot bougie is anchored securely with the lower end of the Celestin’s tube purchase 60caps ayurslim otc. The pilot bougie is now pulled out till the upper funnel-shaped end of the tube impacts against this stricture effective 60 caps ayurslim. This is also introduced through an oesophagoscope after the malignant stricture has been properly dilated purchase ayurslim canada. Sharply angulated tumour at the cardia or near cricopharyngeus and tumours longer than 6 cm in length are less suitable. Nowadays contact method has been used and a lower power of laser light can be used for treatment, thus reducing the risk of perforation. Typical power setting ranges from 50 to 100 w and the energy is delivered in 1-2 second pulses from a distance of about 1 cm from the tumour surface in case of non-contact method. Lasering starts from the distal tumour margin and progresses circumferentially upto the proximal margin. In this technique the oesophageal lumen is always in view and should reduce the incidence of perforation. As yet there is no clear advantage between the contact and non contact methods with respect to the number of treatment sessions, relief of dysphagia or complications. A delay of upto 1 week between initial treatment and relief of dysphagia is typical. Perforation and creation of tracheo-esophageal fistula may occur in 5% to 10% of cases (this is less than intubation technique). In both laser and intubation there is significant initial improvement in quality of life which gets deteriorated in the terminal phase of the disease. At endoscopy the tumour is exposed to 6-30 nm wave length (red light) from a tunable argon pumped dyelasar. Necrosis follows damage to the tumour vasculature by cytotoxic singlet oxygen liberated from the activated pho tosensitizer. These probes are inexpensive and a recent comparative trial has shown it to be as efficacious and safe as laser treatment. It neither improves patient’s general condition nor gives any relief to the patient from the distressing complaint, i. Traditionally radiation is given by external beam from a linear accelarator or cobalt source. The optimum dose for external beam radiotherapy is unknown, but the minimum accepted for radical treatment is 5000 cGy; and more than 6000 cGy often leads to unacceptable side affects. With a daily dose of 200 cGy and 5 treatments per week, a full course of treatment lasts for 5 weeks. But many patients cannot complete the full course of treatment due to poor tolerance. Postirradiation stricture and creation of oesophagorespiratory fistula are serious complications of this treatment. Debilitating effects of radiotherapy may also deteriorate the quality of life remaining to the patient. In fact this gives considerable palliation to squamous carcinoma, though dysphagia may recur which is commonly due to fibrous stricture rather than the primary tumour. Adenocarcinoma of the oesophagus has often been considered radioresistant, but there are data showing little difference in survival rates between patients with adenocarcinoma and squamous carcinoma affecting the cardia treated by radio therapy. The applica tor is fixed at the mouth and the patient is transferred to a protected treatment room and connected to the Selectron machine. In this treatment a single high dose fraction is given to obtain rapid palliation. The great advantage of brachytherapy is that the radiation dose is highest to the tumour while adjacent normal tissues are almost spared, though some patients develop troublesome oesophagitis. A combination of a low dose external beam radiotherapy alongwith intracavi tary treatment is an attractive new development. Response rate with single agent chemotherapy has been poor, but a measurable response rate (20% to 30%) has been obtained when cyclical combination chemotherapy has been used particularly with cisplatin and 5-fluorouracil. Combined chemotherapy (5-fluorouracil cisplatin x 4 cycles) and radiotherapy (5000 cGy) has been compared with radiotherapy (6400 cGy) alone in patients with either squamous or adenocarcinoma. It has been seen to produce considerable shrinkage of the disease in about 60% of the patients. A significant improvement in survival and quality of life have been noticed in combined chemotherapy and radiotherapy group. Surgical bypass is sometimes a major procedure for use in a patient with limited life expectancy. Randomised prospective studies of preoperative and postoperative radiotherapy have not shown much improvement in survival. At present preoperative chemotherapy may be used as oesophageal cancer is a systemic disease and this treatment may improve the results still further in coming days. Their uses in the management of benign oesophageal perfora tion and strictures, relief of pyloric and duodenal obstruction, benign bile duct strictures and obstructing rectal carcinoma are controversial. It is common practice to predilate the stricture using a balloon before employing the stent. When there is no plastic cover the stent adheres to the full length of the stricture as the surrounding tissues project through the mesh and minimises migration. Plastic covered prostheses are protected from ingrowth, but these are more liable to migration. In malignant oesophageal disease at least 50% of patients will be unfit for or have diseases too ad vanced for surgery. Whereas intubation is one-stage treatment, but producing tumour necrosis requires repeated treatment at regular intervals. Dysphagia may be functional mainly due to neurological causes or physical due to pressure on the lumen or foreign body in the lumen. A list of causes of dysphagia is given below to help the students in differential diagnosis : 1. In the mouth : Tonsillitis, quinsy, carcinoma of the tongue and paralysis of the soft palate (due to diphtheria in children and bulbar paralysis in adults) etc. Patients with reflux oesophagitis feel burning retrosternal discomfort as soon as they swallow hot beverages or alcohol. Just distal to this dilatation the gut is connected with the vitello-intestinal duct which opens into the yolk sac. At this stage the stomach is placed in the median plane and is connected posteriorly to the body wall by a short dorsal mesentery, termed the dorsal mesogastrium. Anteriorly the stomach is connected to the distal part of the septum transversum with ventral mesogastrium. Due to rapid growth of the dorsal border the pyloric end of the stomach is carried ventrally and a concavity appears in the lesser curvature. Now the stomach is displaced to the left of the median plane and is rotated on its vertical axis so that the right surface is directed dorsally and the left surface ventrally.
Begin at low ﬂow or regulate the inﬂow to a rate dle has been inserted into the abdominal wall buy ayurslim 60caps fast delivery, place one drop of 1 L/min purchase generic ayurslim canada. The initial reading in the gauge measuring intra- of saline in the hub of the needle purchase ayurslim amex. Aim the needle roughly in abdominal pressure should be 5–10 mmHg if the needle is in the direction of the sacral promontory. After 3–4 L of gas has been through the abdominal wall, one should feel a pop as it injected into the peritoneal cavity, percuss the four quadrants passes through the fascia and another when it penetrates the of the abdomen to conﬁrm that the gas is being evenly dis- peritoneum (Fig. Increase hub should be drawn into the peritoneal cavity owing to the the ﬂow rate until the intra-abdominal pressure has reached negative pressure that exists in the peritoneal cavity with 15 mmHg. At this stage, remove the Veress needle and insert traction upward on the abdominal wall. Direct ing another drop of saline in the hub of the needle and then this device in the direction of the sacral promontory and elevating the abdominal wall to create more negative pres- exert gradual pressure with no sudden motions until it has sure. If the drop of ﬂuid is not drawn into the peritoneal cav- penetrated the abdominal cavity. If this move is tion device to the cannula and continue insufﬂation to main- unsuccessful, withdraw the needle and reinsert it. This initial cannula needle appears to be in the proper position, perform a conﬁr- should have a diameter of 10–11 mm for the standard 10-mm matory test by attaching a syringe containing 10 ml of saline laparoscope. If turbid ﬂuid is Open Technique with Hasson Cannula aspirated, suspect that the needle has entered bowel. If blood returns, remove the needle and promptly insert a Hasson can- The Hasson cannula is designed to be inserted under direct nula as described below and insert the laparoscope to inspect vision through a minilaparotomy incision. Make a scalpel incision through telescope is inserted and the operation can begin. Insert the index Occasionally, there is difﬁculty or uncertainty about ﬁnger and carefully explore the undersurface of the fascia for inserting the initial trocar cannula into the abdomen. Open the peritoneum under direct vision cases, do not hesitate to abandon the blind steps of inserting with a scalpel. The commonest error is to make the incision the Veress needle or the trocar cannula and to switch to an too small. The peritoneal incision should comfortably admit open “minilaparotomy” for insertion of a Hasson cannula. After visual and ﬁnger exploration ascertains that the abdominal cavity has been Management of Hypotension entered, insert the Hasson cannula under direct vision During Laparoscopy (Fig. This cannula has an adjustable olive-shaped obtu- rator that partially enters the small incision. These sutures are used to instruments into the trocars and release the pneumoperito- anchor the cannula and at the end of the procedure to close neum while seeking the cause of the problem. The increased intra- cannula, which ﬁrmly anchors the olive obturator in the inci- abdominal pressure is not always tolerated, especially in sion and prevents loss of pneumoperitoneum. Scott-Conner frequent use of reverse Trendelenburg position and rela- tive hypovolemia due to bowel preparation or overnight fasting prior to surgery. Often the procedure can resume if additional volume is infused and the insufﬂator is set at a lower pressure. Some patients do not tolerate pneumo- peritoneum, and the procedure must then be converted to an open laparotomy. Subcutaneous emphysema may be the result of an excessively high intra-abdominal pressure. After checking all of these possibilities, the anesthesiologist can generally maintain the patient with hyperventila- tion. This should be suspected if unex- 1999, with permission) pected hypotension occurs during the operation. It is par- ticularly apt to occur during laparoscopic surgery in the vicinity of the esophageal hiatus. This is the only way to become proﬁcient A quick survey of the abdomen with the laparoscope is with the maneuvers needed for laparoscopic suturing and indicated. If the laparoscopic search is not ade- secondary operating ports should intersect at the operative quate, do not hesitate to make an emergency midline lapa- ﬁeld at an angle of 60–90°. If you are uncertain, try out a rotomy incision, leaving all of the instruments and trocars contemplated trocar site by passing a long spinal needle in place. Explore the retroperitoneal area for damage to through the insufﬂated abdominal wall into the ﬁeld under the great vessels, including the aorta, vena cava, and iliac direct vision and observe the position and angle at which it vessels. Trocar diagrams given in textbooks, Secondary Trocar Placement including this one, are just guidelines as each case is slightly different. If you are having difﬁculty, consider whether Place secondary trocars in accordance with the triangle rule: inserting another trocar for additional retraction or to substi- Think of the laparoscope (the surgeon’s eyes) as being at the tute for an ill-placed port might help. It is generally neces- apex of an inverted isosceles triangle with the primary and sary to leave the original trocar in place to avoid loss of the secondary operating ports as the left and right hands, as pneumoperitoneum. For that reason inspect the abdomen with the laparo- Ergonomic Considerations scope and, if necessary, insert one of the ports that will be used for retraction before placing the operating ports. For Once the ports have been placed, adjust the operating table example, when setting up ports for a laparoscopic cholecys- and dim the overhead lights. Then allows the hands to be held at approximately elbow height grasp the fundus of the gallbladder and try lifting it to get a with instruments in the trocars. Because laparoscopic 9 Mechanical Basics of Laparoscopic Surgery 65 instruments are longer than conventional instruments, it is laparoscopic appendectomy. Adjust the position of should have basic laparoscopic suturing and knot-tying the operating table to allow gravity to displace viscera skills. Practice suturing in a box trainer until you are (reverse Trendelenburg for upper abdominal surgery, facile. Trendelenburg for lower abdominal surgery with the opera- Port placement is crucial for successful laparoscopic tive side rotated up). As previously mentioned, the primary and second- sible to position the patient optimally, raise the table and ary ports should bring instrument tips together at an angle of stand on a platform to compensate. Knots may be tied intracorporeally in a manner analo- Because even a small amount of bleeding absorbs light and gous to that used during open surgery or extracorporeally. For intracorporeal as laparoscopic cholecystectomy, monopolar hook cautery tying, the entire needle and suture are passed into the works well. The suture is cut short (generally around cold, as a blunt dissector, and the hook then used to elevate, 10 cm): just long enough to be able to produce the loops cauterize, and divide small structures. The back side of the required for intracorporeal knotting but short enough that hook may be used with cautery as a spatula cautery tip. Generally a pliable tip of the suction irrigator is also a useful dissecting tool. The size of the Curved “Maryland” dissectors, endoscopic right-angle suture must be appropriate to the intended purpose; for clamps, and a variety of blunt graspers are used to stabilize instance, during laparoscopic Nissen fundoplication, and dissect in a manner analogous to that used for open sur- a heavier suture must be used to approximate the dia- gery (Fig.