Lap chole

Lap umbilical hernia

Lap splenectomy

ANal polyecomty

Fissure

Stapler hemorrhoidectomy

Open Hemorrhoidectomy

Pt in lithotomy.
3 arteries at skin side of  2, 6 and 10 o clock positions over hemorrhoids; attached with allis to drapes.
another artery at mucosal side of hemorrhoids.
diathermy to make v shaped incision at

bed sore

double arterial  pressure in 2 hours, therefore 2nd hourly posture change.

new lap app

supra-umbilical 4 cm incision.
gauze and artery used to clear the tissue. 2 retractors
2 arteries used to pick up umbilicus. incised. artery pushed through and dilated.
rod put.
manipulator used to pick up app.
harmonic pressed to full n tissue grasped.
2 loops placed and harmonic used to divide app.
app extracted thru 10 mm port with 5 mm camera.
instruments put and ports extracted to make sure nothing enters.
rectus with 1 vicryl.

log

3/9/2014
Performed Multiple lipomatosis excision- 16 , should have planned the surgery better.

4/9/2014
Performed Inguinal hernia repair - congenital type.

5/9/2014
Observed: Elbow cyst excision
Assisted: Stapler hemorrhoidecotmy
Observed: Gluteal abscess ind post depomedrol s/c injection instead of im.
Dressing: Pramod patil, Lakshmi narayanarao, vaidyanathan,
References:
Perianal abscess/ hematoma in ALL pt,: Ramachandra started on Cremadiet 2 tsp 1 glass water at night time,  planned for ind on 6/9 after SDP transfusion.
 Axilla Folliculitis: Magsulf dressing applied.

6/9/2014:
Performed wound debridement of varicose ulcer feeder vessel bleeding +, vaidyanathan.
Performed slough excision on a post ind over cubital fossa lady.
References: Proctitis/ anal gland infection

8/9/2014

MHB01746325

Uthaiah   BK

07/09/2014

Male

54

1014 LAP UMBILICAL HERNIA MESH REPAIR 2ND ASSISTANT MANIPULATED GRASPER

MHB01307544

Aruna   TRIVEDI

07/09/2014

Female

65

0608ES LAP CHOLE 2ND ASSISTANT MANIPULATED GRASPER

MHB01586214 Bopanna    07/09/2014  Male 34 0557A LAP UMBILICAL HERNIA MESH REPAIR CAMERA MHB01771399 Syed abdul   LATEEF 07/09/2014  Male 80 1019 B LAP CHOLE 1ST ASSISTANT CAMERA

MHB00655784 SOSAMMA MATHAI    06/09/2014  Female 56 0574A LAP SUPRA-UMBILICAL HERNIA MESH REPAIR CAMERA 17/9 MHB01770854 Lissy   MATHAI open incisional hernia Female 49  mesh repair - multiple small defects   MHB01772402 Geetha ebenezar   S lap chole Female 46  FT4 normal, tsh was 16, but did surg anyway MHB00594325 THOPAIAH D   Unknown stapler hem, Male 72  staple line too high, led to retained hem. 1 call of bleed post op MHB01754328 Sushila   TRIVEDI lap chole + lap splen Female 54  divide all atachments, rotate it, apply clip. MHB01776812 Ganganna   H bowel obs due to rectosigmoid growth Male 86    hartmans done, 1 fortwin given by anaest postop

Hernia under LA[] Just a job, if here will work like workers of stanley hostel/ hospital.

Only possible if small hernia
Lig + sensor + hyal + adr
10 ml along incision line with spinal needle
then 10 ml below external oblique before incising

Lap umb hernia
if port comes out, it needs to enter thru same hole, but it is not as big a complication as hitting a artery of puncturing bowel.

fistula in ano
probe passed and then LA given.

Just a jo

We cant do magic

We can remove the focus of infn, but the inflmatn will take time to subside...
Baby has to take 9 months to deliver.

Getting serious about surgery

Today got serious about surgery bcos was not being taken seriously here.
post normal lap app

post bad lap app

post norml chole

Diverticulitis

started on npo ivf
magnex forte, ornida
today on liquid diet as passed loose stools

fecal impaction

peglec 1 satchet given yest.
pt passed stools
today soft diet with t. cintopro 3 mg od

DM foot nec fascitis

skin well demarcated, pallor and blue.
fascia black, not bleeding,
foul odour
seen over base of toe. tip of toe pink.

post lap app/ tep

orals from 6 hrs, sips to 30-50 ml/hr clear liquids as tolerated.

FNAC thyroid

fix swelling after painting with betadine
24 g needle 10 ml syringe
insert needle with 3 ml air. pull with index and middle finger back.
pull back 6 times
change direction in the middle.
keep 6 glass slides ready
inject into1. withdraw air, push into 2nd slide. take 2nd slide and drop over 1st to make smear, then slide each over the other.
put into kopliks jar.

yellow is to red is to blue is black

Yellow: infected degradable waste. No harmful fumes on burning.
Red: infected non degradeable waste. Harmful fumes on burning.
white: sterile plastic
Black: sterile paper and unrelated material.
blue: glass
black box: sharps

Thyroidectomy

points marked on suprasternal notch, 1 finger breadth above sc joint and in middle.
skin crease incision made bw 2 scms with blade spread bw 2 fingers
incision deepened with monopolar until platysma seen dividing.
finger used to pull back skin and show sub-platysmal layer and monopolar used to make slipght plane below it.
jolls retractor placed.
platysma held with 3 allis and pulled up.
.flap raised just below the platysma and above the white cervical fascia.
anterior and posterior borders of scm released n the side of snt.
fascia held up with 2 mosquitos and monopolar incised at midline bw 2 ajv.
ajv can be buzzed with bipolar or toothed and monopolar.
2 sterno hyoids split in middle and allis applied to it, lifted up and separated from sternothyroid.
allis re-applied to lift sternothyroid and plabe created above capsule, all the while pulling thy more and more medially.
Retractor put for muscle.
MTV ligated with 3-0 and divided.
1 fascia is at posterior border. bipolar division done. pusher used to free the space in bw pedicles at  posterior border to reach t-o groove.
index finger and thumb used to hold the lobe and pull it down.
above muscle strands divided with monopolar.
pusher used to make space.
right angle makes window laterally and medially.
and 2 ligatures made on superior pedicale with 2-0, not divided.
thin fascia over inferior pole, mosquito dips and opens above pedicle, dips and opens below pedicle, lift up the thin fascia over pedicle, divide with bipolar.
hunt for rln in t-o groove keeping curve upwards. then hunt for it below thy.
once found follow it upto untry point.
ligate STA again and divide with blade.
 bipolar division of berrys very close to thy gland surface from above descend upto isthmus level.

Di-alysis

Dialysis takes 4-6 hours to finish.

Inj Reflin 1 gm bd - Cefazolin
Inj Magnex forter 1.5 gm bd - Cefaperazone sulbactum
Inj Zienam 500 mg bd/ qid - Imipenem- cilastatin
Inj Ornida 500 ml bd - ornidazole
Inj tavanic 500 mg - levoflox
T. Klox-d 500 mg bd Dicloxacillin
T. Sporidex 500 mg bd Cefalexin for swelling excision
T. Novaclox 500 mg bd
Tab. Ceftum 200 mg bd Cefuroxime
inj dalacin c 300 mg tid for 5 days
tab. dalacin-c 600 mg tid for 5 days
Inj metrogyl 500 mg tds
tab lasilactone 50 mg 1-0-0
Inj Zanocin - oz 100 ml bd ofloxacin 200 + orn 500
Smuth Ointment for hemorrhoids
Inj leuprolide 11.75 mg s/l
Inj deriphylline 1 amp iv tds
Neb Combimist L 6th hrly
Tab Lanoxin .25 mg 1/2-0-0
 Tab Ivabradine 5 mg 1-0-1
Tab Tazzel 20 mg 1-0-0
Tab Dytor plus 10 mg 1-0-0
Tab Domstal 10 mg tid
Tab Cintopro 3 mg od
Tab Cintodac od
Tab Neksium 40 mg od bf Esmo
Syp Sucrafil-o qid
Nu patch 200 mg od
Tab Voveron SR 100 mg od
Tab Combifla/ Enzoflam/ Ultracet sos
Syp Cremaffin 15-30 ml hs
Peglec 1 satchet in 1 litre ( stronger than duphalac)
Oint Proctosedyl before and after foods
Tab Orni-o oflox 200 + orni 500
Inj oflin 200 mg bd oflox
Tab ornida 400 mg bd
Tab Refzil-O 500 mg bd Cefaprozil
Tab Ceftum 200 mg bd Cefuroxime
Tab Novaclox 500 mg bd
Inj Perfalgan 1 gm sos
Inj Tramazac 50 mg slow iv infusion/ im tds
Inj perinorm 10 mg iv tds

Scar on toe with cellulitis

Magsulf dressing left for 2 days with scar left open. Healed well.

IV line thrombophlebitis

Mag sulf dressing * 2 days without opening

Post op bottom case

NPO for 6 hrs f/b clear liquids, if tolerated normal diet.
inj zanocin-oz 100 ml bd for 1 day/ inj oflin-oz 30 ml bd
Anal pack removal at 6 am followed by sitz bath tds warm water with betadine 1 cap f/b placing a gauze pad or sanitary pad over which tight underwear for 15 days.
 syp. cremaffin plus 30 ml tds/hs as per constipation level for 15 days.
loz 2% jelly/ proctosedyl ointment/ smuth ointment if hemorrhoids for 1 week
tab. zanocin-oz 200 +500 mg bd for 5 days/ tab orni-o 1-0-1 500+200/ tab. oflin-oz 200+500
tab. pan, ultracet,

SOFT HIGH FIBRE DIET

Post op fluids after chole

 After 6 hrs, oral sips of water f/b 30-50 ml of clear fluids ( water, juice, coconut) as tolerated by patient not vomiting.
pca, nupatch 200 mg od, ultracet tds, tramazac sos, nupatch to voveran sr 100 mg od from day 1
Pan. perinorm
magnex forte 1.5 gm bd
if cholangitis add amikacin 500 mg od
steam inhalation
mobilise pt at 6 hrs
watch for bleeding, soakage

ALL young age fissure

ALL pt on chemotherapy- develops constipation easily so develops fissure.
Prophyllactic sphicterotomy can be done but nothing after wbc falls.

Aplastic Anemia

Peri-folliculitis - blisters in the cheek occurs without pus as no pus forms in aplastic anemia.

Breast Abscess I n D

1) Infected Galactocele Upper Inner Quadrant

Radial incision over most prominent part of swelling with 15 blade spreading it between two fingers.
Diathermy to deeper layers until thick curdy milk escapes. Pus CS and suction. Push all of it out, then excise also.
Give peroxide injection, betadine and saline wash. Keep betadine 2 gauzes with 1/2 inside and 1/2 outside. Apply pad dressing.

2) Sub mammary abscess
Circum-areolar incision. Wall excised and sent for HPE cos old age.

Cervical LN Excision biopsy

Pre op instructions
NPO from 12.00 midnight on Sunday
PAC and follow orders
Informed Consent
Hiv HbsAg
Shift to OT on call
Inj Reflin 1 gm ATD iv full dose before shifting to OT
IVF as per Nephrologist from morning 8 am

OP
Mark skin crease incision first, then give local
15 blade incise
Diathermy cut
Platysma split longitudinally
Excise with diathermy
CLose with 3-0 monocryl
Platysma longitudinally, sc , skin subcuticular with internal 3 knot at start, aberdeen at end.



Post op instructions
Pt can have normal food.
Inj Reflin 1 gm iv bd
Tab Pan 40 od
Tab Ultracet sos
Inj Tramazac sos
W/F soakage, cn be mobilized
Inform sos

Hickmans catheter removal

Drape and paint.
Small scissors to dilate the opening.
Pull out while keeping pressure over below clavicle.
Apply pressure over both below clavicle and over exit sie with gauze.
Apply more gauze and dynplast over it tight application.

Fissure- Closed Lateral Internal Sphincterotomy

Biflange proctoscope to open after pr.
Adr with lig injection to 3'0 clock
Laternal nick at intersphincteric groove.
Scissors inside initially to plane between sphinters and then to cut internal sphincter.
excise skin tag with diathermy
Gelonet anal pack and t bandage over gauze.

IH Lichenstein

Mark incision.transverse, midway b/w asis n pubic tubercle
Cut dermis with blade.
Diathermy to ext oblique.
2 arteries and silk tie to vessel.
Diathermy to expose upto lower edge of ext oblique.
retractor to upper edge.
Diathermy to divide inguinal ligament and 2 arteries to create space below it and pick it up.
finger below to ext ring and diathermy to cut it.
Finger above and diathemy.
Diathermy to fibres between ext oblique and cord
Protect nerve or tie above and clamp below.
Create plane above and below with diathermy and finger.
Pick up cremaster by 2 arteries and diathermy in between.
Diathermy to plane between cremaster and cord, on both sides excise cremaster.
Another nerve comes laterally. tie above and clamp below.
Transfix the nerve with lateral cremaster.
Diathermy to plane between sac and cord. upto deep ring distally and pubic tubercle proximally.
 Posterior wall closed from medial to deep ring with littles repair with 3-0 PDS
MESH 3"X6"
2 cm from long edge and 0.5 cm from s

Oral fluids

started 5 hrs after ga, 6 hrs after spinal.
oral sips of water as tolerated ->clear fluids orally 30-50ml/hr->100-120 ml/hr. -> liquid diet kanji-> soft diet.
ivf dns/rl 100ml/hr->50 ml/hr-> stop.
 

Pressure sore foot

Surrounding callosity scraped with 22 blade.
Peroxide, betadine gauze applied.

Papilloma Scalp excision

Shave hair circular area around it.
LA + Adrenaline.
15 blade, incise around it.
Peroxide, betadine gauzes.
Suture edges.
Apply healex and leave open.

Mucous retention cyst lip excision

Gauze piece inside mouth.
Clean and drape.
LA both sides
Thin incision like sebaceous cyst. Plane underneath the mucosa, by holding it with Adsons.
Excise and close with Catgut 3-0.
Keep gauze piece to hold over it or leave it open.
 

Lap endometriosis, sterilization

uterus plastered to rectum.
ovary multiple cysts.
plane created to free uterus, very bloody.
ovary cysts drilled into n clear fluid released. Ovary preserved as pre-men
salphingectomy done for sterlization but banding can be done.
upper half of ovary with many cysts excised.

Hypokalemia mgmnt

Medscape
Patients who have mild or moderate hypokalemia (potassium level of 2.5-3.5 mEq/L) are usually asymptomatic; if these patients have only minor symptoms, they may need only oral potassium replacement therapy. If cardiac arrhythmias or significant symptoms are present, then more aggressive therapy is warranted. This treatment is similar to the treatment of severe hypokalemia.
If the potassium level is less than 2.5 mEq/L, intravenous potassium should be given. Maintain close follow-up care, provide continuous ECG monitoring, and check serial potassium levels.

Intravenous potassium, which is less well tolerated because it can be highly irritating to veins, can be given only in relatively small doses, generally 10 mEq/h.
Under close cardiac supervision in emergent circumstances, as much as 40 mEq/h can be administered through a central line. Oral and parenteral potassium can safely be used simultaneously.

Monitor for toxicity of hypokalemia, which generally is cardiac in nature.

Uptodate 
For patients with severe hypokalemia due to gastrointestinal or renal losses, the recommended maximum rate of potassium administration is 10 to 20 meq/hour in most patients. However, initial rates as high as 40 meq/hour have been used for life-threatening hypokalemia [2,46-48]. Rates above 20 meq/hour are highly irritating to peripheral veins. Such high rates should be infused into a large central vein or into multiple peripheral veins.
Potassium can be given intravenously via a peripheral or a large central vein. To decrease the risk of inadvertent administration of a large absolute amount of potassium, we suggest the following maximum amounts of potassium that should be added to each particular sized infusion container [47,49]:
●In any 1000 mL sized container of appropriate non-dextrose fluid, we suggest a maximum of 60 meq of potassium.
●In a small volume mini-bag of 100 to 200 mL of water that is to be infused into a peripheral vein, we suggest 10 meq of potassium.
●In a small volume mini-bag of 100 mL of water that is to be infused into a large central vein, we suggest a maximum of 40 meq of potassium.
Intravenous potassium is most often infused in a peripheral vein at concentrations of 20 to 60 meq/L in a non-dextrose-containing saline solution. Use of an infusion pump is preferred to prevent overly rapid potassium administration in any intravenous container with more than 40 meq of potassium or if the desired rate of potassium administration is more than 10 meq/h. For patients with severe hypokalemia, administration in a large central vein is preferred if this access is available

he necessity for aggressive intravenous potassium replacement most commonly occurs in patients with diabetic ketoacidosis or hyperosmolar hyperglycemic state (nonketotic hyperglycemia). These patients typically have a substantial reduction in potassium stores due to urinary losses, but usually present with normal or even high serum potassium levels due to transcellular potassium shifts. Patients who present with hypokalemia have an even larger potassium deficit [46]. Furthermore, treatment with insulin and intravenous fluids will exacerbate the hypokalemia and minimize the efficacy of potassium repletion. Thus, insulin therapy should be delayed until the serum potassium is above 3.3 meq/L to avoid possible complications of hypokalemia

 Although isotonic saline is often the initial replacement fluid used in treating diabetic ketoacidosis or nonketotic hyperglycemia, the addition of potassium will make this a hypertonic fluid (since potassium is as osmotically active as sodium), thereby delaying reversal of the hyperosmolality. Thus, 40 to 60 meq of potassium per liter in one-half isotonic saline is preferred.

Potassium repletion is most easily accomplished orally but can be given intravenously. The serum potassium concentration can transiently rise by as much as 1 to 1.5 meq/L after an oral dose of 40 to 60 meq, and by as much as 2.5 to 3.5 meq/L after 135 to 160 meq [42,43]. The serum potassium concentration will then fall back toward baseline over a few hours, as most of the exogenous potassium is taken up by the cells 

Potassium must be given more rapidly to patients with hypokalemia that is severe (serum potassium less than 2.5 to 3.0 meq/L) or symptomatic (arrhythmias, marked muscle weakness, or rhabdomyolysis).

Patients with gastrointestinal losses are treated with potassium chloride if they have metabolic alkalosis (as usually seen with vomiting) or a normal serum bicarbonate concentration, and with potassium bicarbonate (or potassium citrate or acetate) in the presence of metabolic acidosis (as seen with diarrhea or renal tubular acidosis). Treatment is usually started with 10 to 20 meq of potassium given two to four times per day (20 to 80 meq/day), depending upon the severity of the hypokalemia.

Potklor solution provides 20 mEq K and Cl per 15 ml
syrup potassium chloride in the dose of 1–2 mEq/kg/ day (15 mL of syrup potklor provide 20 mEq K).  

Fistula

Special- EUA/Fistulotomy under GA- 2-3 days - 70-75000
Pre-op
NPO from 7 am after light breakfast on same day.
IVF DNS/RL 100 ml/hr.
PAC review and follow orders.
Prepare perineum and private parts.
Well Informed Consent.
Inj Zanocin OZ 100 ml iv 1/2 an hour before shifting.
T. Dulcolax 2 hs

Op
H2O2. Curved Probe. LA with Adrenaline injection. Incise over probe. Cut with diathermy around tract. Turn probe either side with and cut. Scrape with scoop after excising. fold a gauze piece to form diamond. Wrap it with jelonet. Pack the wound. Gauze pad and T bandage.

Post-op (3-5-3)
NPO for 5 hrs f/b oral sips of water -> 30-50 ml /hr if tolerated.
IVF dns/rl 100 ml/hr.
Monitor vitals.
Inj Zanocin-OZ 100ml/hr.
Inj Pantodac 40 mg od iv
Inj. Perinorm 10 mg tid iv
Inj. Tramazac 50 mg im/ T. Ultracet sos.
Syp. Cremaffin plus 30 ml hs.
Mobilize after 6 hrs.
Watch for bleeding/ urinary retention.
Inform sos.
POD1
Sitz bath tid.

Lipoma forehead

Daycare- Excision under LA- 1 day- 20-25,000
Pre-op
Pt can have normal breakfast., NPO after that.
T. Levoday 500 mg stat
Monitor vitals/ Informed Consent/ Shift to op on call.
Op
Exact skin - crease marking and incision
Bipolar and scissors excision
Post-op discharge
Keep the dressing dry
T. levoday 500 mg 5 days od
T. ultracet sos / pain tds
Review after 1 week for s/r

lap app

pass urine pre op.
2 arteries to stretch umbilicus. Incise with 11 blade. Pass another artery inside n dilate. Pass rod into perit while lifting supra pubic area with towel grip. Pass cannula over rod, n remove It. Attach gas. Telescope connect, attach light source. White balance n focus. Pass inside. Suprapubic n suprapubic ports.
Rod inside to finger push. Monopolar hook n bipolar cautery.
base ligated with 1-0 chromic. Excised in bag.

abscess i n d

paint with betadine.
LA sub dermal wit brown needle 5 ml
1 cm stab incision.
pus c/s taken.
loculi broken,wit straight.
scoop taken n cavity scraped,
peroxide gauze inser inside n let it act.

betadine gauze wick or betadine packng done.