SOPS OF SURGICAL UNIT Mt JHL GENERAL SURGERY oe Howtos g 2. Admission in $b 3. Emergency day 4. Elective list 5. Guldelines regarding hepatitis 8,C and HIV positive patlents In operation theatre Operation notes ‘Antibiotic policy. Post Op analgesia 9. Day case procedures + 10, Per rectal examination 14, Foley catheterizationp « 12. Cervical lymph nade blopsy 13, Central venous tine 414, Chest intubation 15. Cardiac tamponade 16, Clreumeision 17. Hand infections 18, OVT 19. Bed sores 20. Fistula tn Ano 21, Haemarthoids 22. Haemorthoidectomy 23, Entral feeding 4. 25. Diabetle foot 26, Ariputations 27. Mesh repair 40 28. Bowel procedures 29, Appendectomy 30. Mass RIE 31. Colostomy 32. Fecal fistula 33, Peritonitis 234, Incision for eXploratory laparotomy 35, Abdominal adhesions 36. Enteric perforation 37. Jaundice 38, Pre-Op preparation for obstructive jaundice 39. Cholecystectomy 40, Post op biliary leakage 41. Splenectomy 42. Thyroidectomy 43, Flbroadenoma 44. CA Breast 45, Varleose velnt 46, Cystle scrotal swelllngs 47, Testicular neoplasm AB, Burn patlents “€3, Acute pancreatlts 50, Statement on principles gulding care at thy fife 51+ belies HTL 2+ re juts [5+ Dundend tj os. Gp piapestnat Herrera SPECIALITY 1. Blood transfusion 2. Bleeding diathesis 800 - Hematuria 6. Renal stones 7. Acute renal failure . Pheochromacytama co real. Scanned with CamScannerwe oS SOP’S OF Hospital dress 1: pt will be advised at time admission to come in loose and nea, clothes 2:no jeans , poloshirts belts and shorts (Bermodas) are Adviseg 3: No under garments during hospital stay 4: At the day of operation pt would be provided hospital dress 5:Hospital dress would of cotton with elastic binders 6: The dress sos have ward name and logo 7: In case of socking with blood ,pus ,urine or secretions dress shoy, be immediately changed 8:The dress would be taken back from the pt at time of discharge an, would be sent fos laundery 9:In case of socking with blood of HCV or HBV positive pt,the dress would be kept in separate plastic bag and will be incinrated Dechy _wengit —Deee cot, & hee = Ne Lee 8 ap OL Drete mek, alboot ta wrerd. WO- woo Deh Ae erp OT Y BU A heme Rb yett ; Wards WE dete LY OT we yee’ Cot eed Nee “Kage Ue we . a fo” chee con a ot aay . ae R woe pS Scanned with CamScannerSOPs Of Admission in Surgical unit 3 Category 1 { Elective cases) Uncomplicated inguinal hernia, Uncomplicated Paraumblcal hernia, ehronle choleeytts,MNG, Vareose vein, Fecal Fistula ete ‘ategry2(0P0 cases) : Malignancies, reducible heria, Obstructive Jaundice, Critical lb ischemia, Fsutein Ano ete” (Category 3 (Emergency cases) Obstructed Heri, intestinal Obstruton, Peroni, Abscess, Acute Ub scheml, Trauma * Patients of Category 1 will be investigated on OPD basis, take time from list incharge and follow ‘the ward protocols of elective list. * Patients of Category 2 willbe Investigated on Fast track basis before admission, except the patients with malignancies(operabe) who can be benefited with early management, wil be (referred for admission, ‘+ Referral cases from tertlary care hospitals will nat be entertained, Scanned with CamScanner| : | S.0.Ps of EMERGENCY DAY e Everybody will be available on emergency day ® On leave/station leave doctor will clearly info, to the registrar » Consultants. will be available round the clock ® Senior registrar on duty is responsible for all workings in emergency ® No operative work is allowed in the absence o| Senior registrar © Response time maintenance is duty of senior PGR in emergency e All critical events will be dealt by S.R and consultant will also be taken on board ® No hesitation is needed in consultancy with consultant even at 12 mid night Emergency call starts at 6am and finishes at 6am next day. Even Patient reports at 5.55 am will be considered case of $3 ° Effort will be made to clear al} Cases as quickly. as possible , Scanned with CamScannere In case of any disaster, protocols of disaster will: be followed ® No patient will be referred to other hospital © No patient will be refused for treatment in emergency ¢ Complete records of patients coming in “emergency will be maintained @ The log book of E£.0.T will be discussed next day’ in morning meeting @ Record of all medicolegal cases will be taken in custody by the registrar © Documentation of H.Os, PGRS, treatment provided and discharge slips should be very ‘clear and in legible hand writing ,sign and stamp. Scanned with CamScanner1 Department Of Surgical Unit. ELECTIVE LIST SOPS ELECTIVE LIST SOPS it with u On list patient must have been Seen by consultant wi oun, and pre operative investigations, 4 in complex major Surgery, ICU, cardiologist and other related gy ‘must be on board pre operatively, 5. 'n case of frozen section, confirm Availabilty of pathologist (wither umber) 2 day before surgery, 6 OT timing is 8 am, so all doctors ‘must be present 15 minutes ear 7:45am), 7 First case should be on table at 7:55am, before arrival of anesthetist, 8 Availability of o Medicine should be ensured from oT Rurse andt Medicine ‘Should be Present in oT at 8a im, 10, Scanned with CamScanner11. 12. 13, 14. 1s. 16. 17. 18. 19. 20. 21. Left over medicines must be returned to patient at the end of operation OT list will be discussed again with Professor at 8pm. Arrangement/flo of cases on list must be asked pre operatively. Children will be operated as a first case. Clean cases preferably operated earlier. No complex major surgery will be done after 11 am. Whole team deputed for each OT will be responsible for implementation of WHO safety check list. Operation notes in register will be entered by first assistant and register will be presented to Sr.Registrar at the end of list. On ‘every first list of month all OT notes will be countersigned by Professor. Biopsy specimen will be handed over to patient’s attendant with receiving signature of attendant. Biopsy form will be filled legibly by 2" assistant and specimen will be send to pathology lab just after completion of surgery. Biopsy register will be countersigned by registrar at the end of list. 2 Scanned with CamScanner. hi 22. Patient postponed due to any reason will be counselled by list in Chay - atient post r coun registrar/ Sr. registrar and reasons will be explained. 23. Full cooperation will be done with anesthetist. Nobody will f, : anesthetist to anesthetized patient if he/she is not willing/satisfied, 24. Full regard will be given to OT nurses. 25. Full care and training will be extended to OTAs and other Paramedics, 26. In any uncomfortable situations, senior Most members of Surgical team OT must be taken on board, 27. All Sr.registrar, registrar, reside nts and house officer will stay in OT till th: completion of last surgery, 28. After completion of Surgery, Primary surgeon/; Patient post opera tively in war assistant must visit th d/icu, oe 29, Theme of team work will be maintained during list. Scanned with CamScanner| GUIDELINES REGARDING HEPATITIS B .C AND HIV POSITIVE PATIENTS IN OPERATION THEATRE : 'deally there should be nominated separate operation theatre for such patients. Operation should be done at the end of list. Efforts should be made that surgery must be performed by a senior surgeon. Surgeon should wear high ankle covering boots , disposable, protective goggles. He should wear double gloves and ensure that all measures regarding PPE must be fulfilled. _ Surgery should proceed smoothly , preferably junior members of team should not assist. Nurse should transfer instruments in a safe way using tray. There should not any hand to hand transfer specially sharps like syringes and blades. Assistant should continuously use sucker to suck smoke while cauterization. 10. Patients draping should be done with disposable drapes. 11. Drapes , used sponges , gauzes , dressings and other things soiled with blood or patients secretions should be incinerated. 12. Inadvertent pricks should be reported and standard SOPs of inadvertent pricks should be followed : In all such incidents , area should not be squeezed but cleansed with pyodine gauze. In Hep B prick sample taken for hepatitis surface antibody immediately. S Iftitres are adequate and one is already vaccinated , no treatment required. ‘* If titres are low and one is non vaccinated , vaccination and immunoglobulins against hepatitis B should be administered. © In Hep C prick do antiHCV after 3 months. © If positive get a PCR report and start anti HCV therapy after consultation from liver PPweNe pena clinic. «Incase of HIV / AIDS go for HAART therapy. Scanned with CamScannersoggles. be dtassist, des. vatients ould gauze. liver SOP’S OF Operations Notes 1: OPERATION NOTES SHOULD PREFERABLY WRITTEN BY SURGEQ, HIMSELF OR SURGEON SHOULD DICTATE TO THE SENIOR MOsT ASSISTANT 2: OPERATION NOTES SHOULD BE WRITTEN IMMEDIATELY AFTER SURGERY OTHERWISE MANY IMPORTANT OPERATIVE FINDINGS AN STEPS MAY BE WASHED FROM SURGEONS MEMORY 3: OPERATIVE NOTES SHOULD INCLUDE FROM INCISON TILL CLOSUR, 4: IN CASE OF UNUSUAL OPERATIVE FINDINGS SCATCH OF OPERATIV FINDINGS MAY BE DRAWN ON THE NOTES S:IN CASE OF MEDICOLEGAL CASES THE OPERATIVE FINDINGS THE OPERATIVE NOTES WOULD BE WRITTEN BY REGISTRAR AND WOULDE KEPT IN CUSTODY OR LOCK AND KEY 6: OPERATIVE NOTES WOULD BE CHECKED RANDOMLY ON AND OFF 8 CONSULTANT (ASSOSIATE OR ASSSISTANT PROF) 7: OPERATIVE NOTES MUST BE SIGNED BY THE WRITING PERSON AND COUNTER CHECKED BY THE OPERATING SURGEON Scanned with CamScannerANTIBIOTIC POLICY ELECTIVE CASES: Clean Operations (Thyroidectomy, Mastectomy, Hernia) 1.gm (double dase) Injection Cephalosporin 1 generation (Cephradine) intravenously at the time of induction of Anesthesia then 3 doses post operatively. No antibiotic at discharge. Mesh Hernioplasty: ~Fnguinal Hernia: /V antibiotics for 3 days ~~ Paraumblical Hernia: I/V antibiotics for 3 days Vincisional Hernia: I/V antibiotics for 5 days & injection Amikacin Clean Contaminated Operations 1), Cholecystectomy: Inj.Ceferuxime (Inj. Zinacef} 750 me/ Inj, Ceftriaxone ({nj. Cefotec) /V at the time of induction, then 3 doses post operatively. No Antibiotic at discharge. 2) Appendectomy: “Inj.Ceferuxime {Inj Zinacef) 750 mg/ Inj. Ceftriaxone (Inj Cefotec) /V at the time of induction, then 3 doses post operatively Plus Inj. Metronidazole 3 doses No Antibiotic at discharge. Contaminated Operation (Complicated Appendectomy, Complicated Cholecystectomy) 1nj.Ceferuxime (In) Zinacef) 750 mg/ In. Ceftriaxone (In. Cefotec) /V atthe time of induction of anesthesia. ‘Administration of I/V antibiotics for § days postoperatively. No Antibiotic at discharge. Scanned with CamScannerDirty Operation (Peritonitis In, Ceferuxime (in. Zinacef) 750 ma/ In}. Ceftriaxone (In. Cefatec) VV atthe time induction of anesthesia. ; F oral intake of the pati Post operatively I/V antibiotics according to the status of or Palin orally (Ciprofloxacin + Metronidazole) for 2 weeks. SPECIAL CIRCUMSTANCES ns: 750 mg/ Inj. Ceftriaxone (inj. Cefotec) I/V at the time of induction of anesthesia. eee 24, FAG Seong ‘ux Of fo © ay ‘Administration of antibiotics for(3weeks postoperatively. 2) Dudenal ulcer perforatio! 'ni.Ceferuxime (Inj. Zinacef) 750 m@/ Inj. Ceftriaxone (Inj. Cefotec) 1/V at the time of induction of anesthesia. Post operatively Klaricid + Metronidazole for 14 days. * repaint qe 3) Post D&C and gynaecological peritonitis: Ciprptloxacin + inj waist attime of induction and then continue for 24 day. 4) Diabetic Foot Dise: ae Emperic antibiotic (Augmentin] wll be started only if there i increased TLC, celts and history of fever. Culture will be taken and antibiotics would be reviewed according to culture and sensitivity report. 5) Syngestic gangrene and Nei roti: Fascitis: {r) lmipenum (tinum) + Inj. Metronidazole initially for atleast 5 days then review “antibiotics according to culture & sensitivity report, 6) UTI: Emperi antibiotics (ciprofloxacin) and then review antibiotics after culture and sensitivity report. 7) Perianal Surgery: In fissure, fistula, uncom; Scanned with CamScanner8) Post operative Wound Infection: ~ Wound will be laid open. Pus will be sent for C/S and then antibiotic will be reviewed, - Le OA RISE EA vseee TE avenue SECO ¢ ew due 9 cbr TSC: Scanned with CamScannerSOP’S FOR ADMINISTRATION OF ° ANALGESIA POSTOPERATIVELY FOR PATIENT OPERATED UNDER GA: Analgesia in Complex major procedures like: (i)Thoracotomy (ii)Pancreatectomy (iiJEsophagectomy (iv)Gastrectomy «Preemptive analgesia in form of epidural catheterization which will continue as postoperatively analgesia (4 to Sdays) & intermittent inj. of nalbuphine © Plus f Vy - Poveco} (v Rowen * IM diclofenac Na SOB (till pt. is NPO), then * Oral diclffenac Na kU N We Co, ‘Analgesia in major procedures like: (cholecystectomy (i)Thyroidectomy (ii) MAM. * Clean operations should be treated with infilteration of bupuvicaine(preemptive) © Plus Nalbuphine (2,4,6 mg) according to weight 4hourly for 24hrs, then 4mg SOS for 3days de © Plus Inj. Diclofenac Na IM 8D for 24hrs, then * Oral diclofenac Analgesia in moderate operations: * Inj. Nalbuphine (2,4,6 mg) acc, to weight 4 hrly for 2ahrs . © Plus * Oral diclofenac Na for 3 days { Scanned with CamScannerFOR PATIENT OPERATED UNDER SPINAL OR SADDLE ANESTHESIA: Analgesia For moderate operations: * Inj. Nalbuphine 4mg SOS for 1" 24hours = Plus * Oral paracetamol (tab. Or syrup) Analgesia for minor operations: Minor operations include: {J)Lymphnode biopsy (ii) Procedures done under LA (iii) Removal of subcutaneous lymph node + Oral paracetamot PROTOCOL FOR ANALGESIA UNDER SPECIAL CIRCUMSTANCES: 1.Chest injury: Should be treated as under: © As of complex major « Intercostal nerve block may be needed 2,Pain of advanced malignancy and painkiller in palliative care: ¢- Inj./Oral Tramadot HCL (acc to status of pt.) 3.Analgesia for terminal ill pt. not responding to tramadol HCL: jhine sulphate tablets(MST) and these tablets are demanded © Morp! ig with 10,15,30mg SOS Shaukat khanum hsptl startin CAUTION: given in presence of doctor « ALLTV analgesics will be itl be mentioned and pt. age,c + Inall analgesics dosage Wi be considered o-morbidity,CLD ete Scanned with CamScannerpay case protocols -oPD days. «No procedure is allowed on emergency OF Timing should the between 9am to 12 MD. No procedure is allowed th: OMe ty, There will be only 5 cases per day. 2 At patients must have registration previously ( booking = Documentation must be proper. Consent form for every procedure must be signed by him or herself orin case ofn, guacdian. 4 «The procedure list should be displayed after morning round . ‘That tist should be made under supervision of on duty SR and should be markedtg,, doctors of day case team. Day case team should comprises of the following : + > Designated doctor > Istaff nurse > Chief dresser (GM) > assistant dresser eAvard-sweepet The doctors should wear OT like dress with proper cap and mask. Allefforts must be done to maintain aseptic measures - «No procedure is allowed without supervision of batch incharge. Individual SOPs of relevant procedure must be followed . “There must be cxygen cylinder and resuscitation tray at hand. After procedure, patient must be kept for Sometime ( at least 1 hour or according tot procedure ) in daycase room and condition at the time of discharge ( satisfactory )ms documented. Patient must be given valid discharge slip. At the end of the list, day case room must be carbolized, Scanned with CamScannerPROCEDURES ALLOWED IN MINOR WARD OPERATION THEATRE (S2) + Greumscion upto 3 months + True cut biopsy Superficial ipomas 3 days = Appendicular mass = Appendicular abscess * Uncontrolled bleeding diathesis = Acute Ml in Last 3 Months Lorn calles Cperaia of | . 1a s Fenas + Tae] ae vey’ rma 10K mec pre of cal, ncoonpht remak: marin Sho be lnggu Gen OF , Ke . " 4) A eppreter ott Wag moa 4 Yo bowing 1 pouere: ote, pur decin” dh perl pt oe Wo G4 pnans en vlatipe - cl insane ee gn. . Left Leas ‘ Scanned with CamScanneroline 2.0 suture at Periphery , S 14-Mesh will be quilted with pr . at the various points on the centre ", 15-Operative site and surrounding skin will be thoroughly adhe warm isotonic saline 16-Adequate size high vaccume suction drain will be placed 17-Adequate functioning of the will be checked 18-subcutaneous tissue will closed with vicryl 2.0 suture 19-Past-op I/V antibiotic will be given for three days 20-drain will be kept till discharge reduces to <20cc 21-Operating surgeon himself is responsible for taking out the drain Scanned with CamScanneru Antil P/O Flagy, P/O Neomycin/ vibram ind ein / Erythromycin or VV Cephalosporins for 48 hrs @ induction of anesthesia eta OF WV Cephatosporins for 48 hr “Lof anesthesia 3" Pre-o) Day: > Diet Semisolid (low residue diet) Milk, Yoghurt, Tender ‘round well cooked meat, moderate fresh aderate fresh without pee Fults, Eggs and Poultry Well cooked vegetables 2 Pre-op Day: > Clear Liquid diet Carbonated beverages, hot or cold coffee, fruit drinks with no pulp or pieces, On celd coffee, fruit drinks with no pulp or piece Apple, grapes or other clear fruit juices 1" Pre-op Day: + Water * NPO after 12:00 MN * Tab. Dulcolax 4 x Stat at 2:00 pm ab. Dulcolax 4x Stat at 2:00 pr «Inf. R/L 1000cc I/V x stat + 1Amp. Of Multibionta > Enemas (Kleen): 1* at 6:00 pm 2" at 10:00 pm ~ 3% at 6:00 am (Morning of Surgery Day) ‘ Scanned with CamScannerAppendectomy YY story if IF (proceed fo, 1 history , Periumbilical pain shifted to RIF (p! an Typical history , Investigations Blood complete *-Urine complete © Anti HCV, HBsAg ¥ Ultrasound abdomen and Pelvis h equivocal cases Teke opinion of Gynecologist _in_Jeralk Procedure * Grid iron incision, NO LANZ in.emergency procedure * Deliver cecum , Note contents in peritoneal Cavity , pus, fibrin, at © contents in peritoneal ca ny FAPPENDIX seems to be normal vv Extend the incision & Examine terminal 2 feet of | ileum (meckel’s diverticulum ) “Mesenteric iymph nodes et lymph nod: “Right Fallo ian tube, Ovary “Right ureter Secure mesentery of a - Crush base of appendix endix “Apply Surture, discard knife with @ppendix in a se, arate kidney dish ce erry 2 SEN Hey ce Ensure hemostasis © Close Peritoneum With vicryl 2-9 we, Approximate Internal Oblique ang Tra Vicryl 2.9 : METSUS Abdominis with intenp Scanned with CamScannerSOPS OF MASS RIGHT ILIAC FOSSA Working diagnosis: Diagnosis on history: Neocecal tuberculosis Young hx of mass, Night sweats, evening rise of temp , be hx of pulmonary. my tuberculosis, hx of gota formation/ intermittent Subacute intestinal obstruction ——————— CA cecum or semi colon ~~ | Middle aged patient, hx of | weakness ,palor, lethargy , altered coloured stools and anorexia. (patient should be discussed in tumor board ) Clinical examination; Tuberculous patient would be of low BMI, mass in RIF In malignancy , patient would be pale , weight loss Investigations: Lower G.l endoscopy (Colénoscopy) (firm to hard with may or may not be present Features of small bowel |, mass may or may not be obstruction} palpable clinicaly. Patient with tuberculosis | Patient with malignancy have high ESR and C- there will be microcytic reactive protein, hypochromic anemia. Do advice fecal occult blood . There would be high There should be a cecum and other organs | fungating tumor mass , Would be unremarkable. | biopsy should be taken and rest of the colon should also be seen, CT Scan with WW and Oral a and Ore contrast (Helical CT) ee Strictures or Narrowing of cecum or of terminal ileum. Polypoidal fungating mass, lymphnodes may or may not be involved , liver may or may not have metastasis. PLAN: optimization Fast track correction of [As of tb pt anemia and einemia Then exploratory In tuberculous patient go] In case of malignancy laparotomy shouldbe —_| for Limited Radical Right done, Hemicdlectomy . hemicolectomy with Principles of mobilization, devascularization resection and anastomosis should be dong Scanned with CamScannerIn tuberculous patients , post operative ATT should be given for 1 year. ———. r pocemitant a in livel can alse nek resected, eB, Same can be don ‘ laproscopically i laproscopic right er, hemicolectomy 0 laproscopic assis hemicolectomy, Teds, In both patients fat free Patient with malign ~ diet and monthly injection | should be referraq : y of vit B12 would be oncology after thar > hat, recommended to avoid the complications of right Hemicolectomy. In compromised patients / ileocecal tuberculosis , emergency ileostomy would be done only and reassessed after completion of ATT. For Inoperable fixeg malignancy of oh TRANSVERSEbypass y be done. I I Scanned with CamScannerCOLOSTOMY } sor’s OF © aca! STOMA SIE ey, pgges MENT REGAROIN Cm 3: RE-OPT ABDOMINAL. POSITION a ER IA. S:PROCEADURE WILL BE DONE UNDE ner SE 6 SumTAate EuPS.F SKIN WOULD BENG UE ZEERUCIATE WCISION WiLL BE MADE ON ‘8100P COLOSTOMY —_— ‘$:CORRECT LOOP MUST BE IDENTIFIED RRECT LOOP MUST BE IDEN” E {ORIENTATION OF PROXIMAL AND DISTAL LOOP MUST BE DON oT) 1 {WN AGE OF somo1o COLOsTOM CEST PROMIMAL PABPOFSIGMOID WITHOUT at p, ‘LOOP IS TAKEN OUT . ‘12:ENSURE THERE IS NO TENSION ON THE LOOP ‘18SUPPORTTHE LOOP WITH PLASTIC TUBING OR GLASS ROD,NO STITCHING OF LOOP WT, ‘14:BEWEAR TO PUNCTURE THE VESSEL OF MESENTERY WHIKLE POSITIONING THE TUBE OR Ry {S:APPLY WELL SOAKED VESLINE GAUZE OVER THE LOOP {NEVER OPEN THE COLON A?THIS TIME 17-ORSERVE THE LooP AFTER 24 HR 18 FE THe Loor FERSE RE WTHOUTANAESTESIA |SVACHIVE PERFECT HAEMOSTASIS AND APPLY TRANSPARENT BAG 2O:OBSERVE THE STOMA FOR WORKING LIKE PASSAGE OF FLATUS AND FAECES: OBSERVE THE STOMA FOR HAEMORRHAGE ,DISCOLORATION AND STENOSIS 22REMOVETHE GLASS Roo /PLASTICTUBING ON S™ nay {EMOVE THE GLASS R00 PLASTIC TUBIN ZIAPPLY PERMANENT COLOSTOMY /STOMA B46 Scanned with CamScannerGUIDELINES TO MANAGE FECAL FISTULA 1. Fecal fistula is reveateg with soat ntents OF Intestinal contents in dralnage ed Of dressing with intestinal co ambigors In equiddl c ie aWSH ca8es the Nstula can be Confirmed with giving oral methylene blue . oral methylene blu 3. Patient should be reassure, 4. Keep the patient npg, é 5. Cllect intestinal content sin cust i sor BY repeated suctions "ustom design ileostomy bag, drain loop’ 6 Skin should be protected with sultable post 1, stoma adhesive tapes, stoma adhesive wafers. Posture of the patien SpArrangements will bewtiAV to place central tne as cary as possible 9. Weight of the patient is recorded, 10. V antibiotics will onty be prescribed if there are local and systemic signs of inflammation. 11. Abdominal ultrasound will be done in the next morning to see the intra abdominal collection of intestinal contents or pus. 12, After Stablizing the patient hemodynamically, that usually takes 2-3 days, parenteral nutrition will be started on its standard protocols. 13, ASSESMENT : Decide whether the fistula is high intestinal , mid intestinal or ‘ow intestinal by noting the amount , color and consistency of the contents. i 14. f the fistula is more than S00cc in 24 hours then its called high output fistula: Kone Response +e fit Scanned with CamScanneror incomplete by notic; her the fistula Is complete or inc y eg, 15. Decide whether . patient to pass flatus. 16. Ifon radiological investigatjon: recorded then drainage should be h open technique. ms Ilection of pus or intestinal con, s,col : ical control or pe, Nts, rey! done on radiologi per vaginal ,or with i lete , then low is di low.gutput and incomp! t 17, If the fistula is diagnosed as i ‘high protein diet containing s000cal /24 hour /70 kg person wil be tang 18, Rectum will be evacuated daily with glycerine suppositories and every % day weight of the patient is recorded. sit wW 19, This conservative treatment will be continued for shemenths ,if there isy not control of fistula / healing of fistula , then CT scan of the abdomen Willy done with oral _and-I\N-contrast. 20. Exploratory laparotomy will be done by one of the senior surgeons on gj, list. 21. Strategy of thé operative procedures will be according to per operative findings. In all procedures resection of fistula along with tract is made. 22. Resected segment will be sent for histopathology. | Scanned with CamScanner| ¢ After resuscitation and Investig Laparotomy >» Give Midiine incision » Record all the findings » Take sample of Peritoneal fluid If present ® Do peritoneal Tolleting of at tt subdiaphragmatic spaces , both iliac fossae + Paracolic gutters and pelvis. » Peritoneal lavage with 3-4 liters of warm Normal Saline » Identify and treat the cause > Take samples for histopathology > Place 24- 28f drain f » Close abdomen in 1 layer with Protene 1-0, 3 times the length of incision > Leave the-skin-and-subcutaneous tissue open Give post op antibiotics for at least 14-21 days. AON, prepare the patient for Scanned with CamScannerSOPS of PERITONITIS © Take complete history and do thorough examination to tap, Sarin iy clinical diagriosis. ® Look for ABCD and start resuscitation © 02 inhalation \ © Maintain 2 wide bore IV lines and draw blood samples for B; Sah as well as blood grouping and cross match . © Catheterize-the patient and start fluid-resuscitation with Ringer Lactate © Give Antibiotics ( inj Flagyl +Inj Ceftriaxone } ® Pass NG-tube © Attach pulse oximeter and start half hourly monitoring of Pulse, RR and UOP. ® If condition Deteriorates > do Peritoniostomy with 2 tubes of 32f inserted into Peritoneal cavity and continuously irrigated with Normal Salin © Ifstable > Start investigations ™ Plain x ray Abdomen Erect © Plain x ray Abdomen Supine = Usg Abdomen Scanned with CamScanner- : : " SOP'S OF incision of exploratory laprotomy 1: INCISION WILL BE PLANNED, , 2 FACTORS TO TE CONSIDERD ELECTIVE yg, EMERGENCY SURGER 3: AGE SEX AND OBESITY OF THE PATIENT 4: HISTORY OF PREVIOUS OPERATION, S:WELL EQUIPPED THEATRE AND NOT WELL Equipopen THEATRE 3: IN CASE OF tA LORATORY LAPROTORAY wey CLEAR DIAGNOSIS NOT AT HAND CENTRAL A ICISION IS, MADE EQUIDISTANT FROM UMBLICUS SUINCISION WILL BE MADE wiry KNIFE 10:COMPLETE HEMOSTASIS Witt BE ACHIEVED BEFORE OPENING PERITONEUM ‘ALIN CASE OF PREVIOUS ExPLORATORY LAPROTOMY INCISION WILL BE STARTED FROM VIRGIN AREA 12:0NE SHOULD BE AWARE OF 1M, 'AKING A KNICK IN UNDERLINE ABDOMINAL VISCERA SPECIALLY AT UMBLICAL LEVEL. UNE 413:RIGHT PARAMEDIAN INCISION Is NOT RECOMMENDED FOR INCASE OF EMERGENCY IT MAY BE OPTED INCASE OF RIGHT HEMICOLE ‘CTOMY ON ELECTIVE LIST 14:ABDOMEN WILL BE CLOSED BY TENSIO: IN FREE PROLINE SUTURES, LENGTH OF PROLINE MUST BE THREE TIMES THE LENGTH OF INCISION, 16:KNOT WOULD BE BURIED AT THE END IN SUBCUTANEOUS TISSUE, 17: INCASE OF ABDOMINAL WALL TENSION TEMPORARY BAGOTA BAG WILL BE APPLIED 18:IN CASE OF LAPROTOMY FOR PERITONITIS DONOT CLOSE THE SKIN 1S:IT IS THE RESPONSIBILITY OF FIRST ASSISTANT TO. DRESS THE WOUND BEFORE SHIFTING THE PATIEN] Scanned with CamScanner-. SOP'S OF I Incision of exploratory laprotomy .waStOW WAL ML HAN 2 HATORSTONCONRADAU CH A NANamg o i AEG SA SEX AND ON SHY OFTHE Pata {TORY OF PREVIOUS OPERANON sweu coun SWELL EQUIPPED THEATRE AND HOF WLLL Cope HEAT ‘INCASE OF EXPLORATORY: sane Fe ONY LAROTOMY Wien CLEA pIAGasts HO AT HAND CERTRAL 'SMADE CQUIDISTANT FitON UMIILICUS OTHERWISE IT My YAY UE UPPER ABDOMINAL OR LOWER ON CENTRAL ABUOMINAL INCISION. S:TRANSVERSE ABDOMINAL YEARS INCISIONS FON LAPROTOMY ARE FEASIRE ONLY UPTO THE AGE OF 30 S:INCISION WILL BE MADE WITH KNIFE SO:COMPLETE HEMOSTASIS WILL BE ACHIEVED BEFORE OPENING PERITONEUM {2:1 CASE OF PREVIOUS EXPLORATORY LAPROTOMY INCSION WILL BE STARTED FROM VIRGIN AREA 12;0NE SHOULD BE AWARE OF MAKING A KNICK IN UNDERLINE ABO! AA SPECIALLY AT IN UNDERLINE ABDOMINAL VISCERA SPE JMMBLICAL LEVEL. e {13:RIGHT PARAMEDIAN INCISION IS NOT RECOMMENDED FOR INCASE OF EMERGENCY IT MAY GE (OPTED INCASE OF RIGHT HEMICOLECTOMY ON ELECTIVE LIST “M4:ABDOMEN WIL BE CLOSED BY TENSION FREE PROLINE SUTURES, LENGTH OF PROLINE MUST BE ‘THREE TIMES THE LENGTH OF INCISION. {1S:DISTANCE OF STITCH WOULD BE 1CM AWAY FROM WOUND MARGIN ANDF HALF CM INBETWEEN ‘THE SUTURES. 46:KNOT WOULD BE BURIED AT THE END IN SUBCUTANEOUS TISSUE. (CASE OF ABDOMINAL WALL TENSION TEMPORARY BAGOTA BAG WILL BE APPLIED 18: CASE OF LAPROTOMY FOR PERITONITIS DONOT CLOSE THE SKIN {9:TIS THE RESPONSIBILITY OF FIRST ASSISTANT TO DRESS THE WOUND BEFORE SHIFTING THE PATIENT Scanned with CamScannerPost operative abdominal adhesions 1, Post op adhesions should be suspected in all cases of Intestinal obstructiry, having past history of abdominal surgeries. 2. Beware of all the new cases as well as the sequel of laparotomy and laparoscopy. 3. If there is previous history ,always try your level best to enter the abdore through healthy area. 4. Only symptomatic adhesions should be divided, 5. Tensile strength of adhesions is more than tensile strength of gut wall so division should be with sharp scissors. ' 6. Never break fibrous adhesions with fingers. 7. Always stay close to the solid viscera and away from the luminal organs whi ing adhesions. 8. Beware of enterostomies and deserolization of intestines. 9. Small enterostomies / deserolized part can be repaired with overlapping sutures/ Lambert sutures. 10. In case of doubtful multiple injuries to large and small gut , never hesitate tc form proximal stoma. 11.In case of frozen pelvis , always pass folley catheter . 12. Beware of ureters while dissecting on lateral pelvic wall. 13.Irrigate the abdomen, with plenty of normal saline . 14.Never leave deserolized part as such while closing the abdomen. 15. Always wear double gloves and remove the outer pair after washing the abdomen during laparotomy and then re-enter in the abdomen, 16. Efforts and training should be done for laparoscopic surgery as compared to open ones, to avold such complications. Re Bota repent names - bxelude abd. Th tm all Plt & meme « nepemteok adliesire, bank ds. Scanned with CamScannerSOPs of Enteric Perforation In addition to SOPs of Peritonitis © Examine last 60 cm oftterminal ileum * For Upto 3 perforations, close the perforation in single layer with vicyrl 2/0 with interrupted surtures and perform proximal loop ileostomy. ¢ For multiple perforations and when status of terminal ileum is precarious , resect the segment and perform end ileostomy and separate mucous fistula : © Give inj ciprofloxacin 750 mg I/V xBD for 5 days and then oral for next 10 days © Give Inj flagyl till the bowel moves Always take sample of gut for culture of typhoid bacillus © Always take wedge biopsy from perforation or resected specimen for histopathology © Apply transparent bag on the ileostomy stoma © Revise antibiotic regime time to time as per ward and hospital policy and C/S report. Scanned with CamScannerQed URES (SOP’S) FOR AUN ING PROCED My STANDARD OPERAT! und i 5 of ja : : 1, Exclude medical a “on ote eat@S of obstructive Jaundice Hg ‘On clinical exam! «scratches on the body, . palpable mass / gallbladder 2. UT's: + AT = AST * Differential bilirubin level 3. Urine examination: * For urobilinogen 4, Viral markers: # AntiHcy © HBs antigen 5. Abdominal ultrasound: Requesting focus on + Mass around and in ampulla of vater, head of pancreas and bile dy * Stones in bile duct * Gall bladder pathology * Nodes in porta hepatis * Kat skin pathology . * Dilatation of intrahepatic duct and extrahepatic biliary apparatus 6. ERCP; * Indicated if pathology is at lower end of bile duct; diagnostic as well as therapeutic (papillotomy stenting biopsy) 7. MRCP: ‘© Indicated if pathology is in porta hepatis 8. CT Scan: * Indicated i pathology iss 3cm in ampulla of vater, head of pancreas Dr. Fayyar PSR Sn Scanned with CamScannerPreparation of Patient with Obstructive Jaundice for Surgery @ Replenish glycogen storage of liver by oral route and intravenous 10% dextrose water atleast 3 days before surgery Check blood sugar levels thrice a day and give insulin according to sliding scale if needed Check PT/APTT daily especially 3 Days prior to surgery Give inj vitamin k daily 1/M for 3 days aa ni I If PT/APTT not improving , make arrangement of FFPs Transfuse FFPs according to operative protocols just before and during surgery _ py Give oral lactulose (30cc)just before surgery [2 cher, Core galls Give oral metronidazole 400mg , thrice daily for 24 hours / iday before surgery Catheterize the patient just before surgery & Give inj mannitol 200ml over 15 mins, half hour before operation PES Donot proceed for surgery, if uriné output is inadequate. Cr apr | oe in nce Scanned with CamScanner‘omy OPs of cholecystect ». - nes will be operated oe all sto! tted is permi ‘ectomy te agus jlaree gut ,pancrease ang k 1- Only symptomatic 8 ‘ 2 No incidental cholecy’ oa iv 3- Diseases of stomach eat y and clinical examination ey . ith histo! _. xcluded wi ‘SA criteria mus; must be exclude tions according to A t be ti 4- All pre-op investiga’ + must be normal Ny t COU 5- LFTs , PT ,APTT and platele! , 6. ra id ‘omment on gall bladder wall thickness stg es a should c ind size) pericholecystic fluid and cBD vpotecyeteetomy without 7- No resident is permitted lap. Cho! 9- Decision of lap or open cholecystectomy will made by the consultant in charge 10- In case of lap.cholt elective conversion is desired rather the, forced conversion into open choecystectomy (_' ~ 11- Clear documentation of anatomy of calots triangle must be made . 12- Cystic duct and artery will be clipped separately 13- Cystic duct will have 3clips ,2 proximal and i distal 14- _ Fundus 1* method will be adopted in case acute cholecystitis 4 15-- When there are tense adhesions cholecystostomy will be done 4 16- Inall open cholecystect stones and tumors 17- Similarly liver y hiatus ‘omies CBD will be Palpated for e Scanned with CamScanner3. Sponge count and i, * end of procedure ‘nstrument count must be ensured at the - i i 19 Inox ines be placed in all ‘Open cholecystectomies 20- Ine ifficult lap, choli drain will also be placed 21- In all cases Of CLD drain will be placed 22- __ The port site of umbilicus the linea alba will be closed with proline 2.0 z3-__ In case of open cholecystectomy anterior rectus sheath will be closed with continuous Proline suture USG Shot Se wihin (Pda 3° Scanned with CamScannerbiliary leak, rative a t ope pos the drain showing bile with, 2, the! sopPs for acognized wh / *] + itshould be re ted if there is post op abdorhingy i ery. spec + Bilis B r yellow! with active aspiration , tachycardia ,fever oth ultrasound or in , firm + Itshould be con drainage. ecured whether it is correctly POSitione + Drain’s position should be s ind bile and it is more than 100m) do + Ifleakage is mixture of blood a watchful wattng bilious and more than 100m! after A8hrs then Uren + Ifleakage ® tbe arrange d with stent placement within 72 hours, . : Piet tian collection not being drained by drain then emergency ~ laprotomy and open drainage must be undertaken. ; ; + Ifthe facility of ERCP / MRCP not available and the Patient is having leakage of more than 100 ml ; he or she should be referred to dedi hepatobiliary unit. & 2 If referral failed or not possible and there Contamination on diagnosis , emer; Surgeon of on duty team, At exploration , iFneat / clea revealed , T tube should be marae sage Reconstr Vestigated after Stabiliz, Tuction 9} SF bili ‘ation ( ERCP/MRCP) Mary apparaty: wns : NE rents of rinay ever ‘| hepaticojejunostomy ) advised . r injury , Perforation or hole in bile duct - placed, . Scanned with CamScannerSOPs Ps OF SPLENECTOMy { INDICATIONS: EMERGE ive iatrogeni Nev. TRAUMATIC electi¥ Beni injury during g TIC INJURY to spleen and UI relcal ope p-pt referred by physician for sai peratons Necto, spherocytosis, sickle cel] disease and th Fee nT, hereditary . | alesemia 3- vaccination against H. influenza st » Strep. pne meningococcal will be given 2 Weeks before splenec omysss ingo! re, 4-Optimization of i ; f hematological Profile i.e. Hb: .e. platelet>60,000, PT and APTT within normal 10mg\dI, val rans ges s-Grouping and cross matching of blood 6-Arrangement of fresh blood, platelet concentrates and FFPs 7-Pre-op NG tube and@rophylactic Augmentintamoxicillin and clavolunic acid) at the time of induction of anesthesia a 8-Laprotomy through left sub costal incision ) S phenic uh 9-Thorough search for wandering spleen (spleen coli 40-Division and ligation of short gastric ligaments and gastrosplenic ligament and then mobilization and division of shlenolenal ligament 11-be vigilant regarding splenic adhesions and do homeostasis in adhesion as well 12: Ligate artery 1° then vein” 13-Don’t damage tail of pancreas Scanned with CamScanner4 © eatic dl y ligate with proline suture f pancreatic duct injury ligat 14-In case of pa a Spi chonderial space for 5-LOmin i ye och 45-pack the left hypo: 16-Ensure perfect hemostasis i ace 17-Put a drain in left sub diaphragmatic sp: i h, basal atelectasis an jilation of stomach, | 18-Post-op beware of acute dilation of sto cum) plural effusion zeN i st 19- Active physiotherapy and breathing exercises started on the 1 Post-op Morning 20-Start dispirine on 1" post-op day 21-Send specimen for platelet count and Hb 22-Remove subdiapharagmatic drain after 48 hours if output is< 30cc 23-continue Prophylactic antibiotic for 21 days 24-Advice pt to have a card in his\her pocket and send pt back to referring Physician di Scanned with CamScannerThYroideg indication should bo gly, tom pecision should by made by ¢ “OY consult, ant compreliensive Preoneratiy, ave jac] 3 ass and biochemical “ssme 7 V euthyroig Nt pationt should be clinically preoperative investigations: © serum 73, T4, TSH shoul * serum Calcium « IDL ld be With In 14 days Operation should be done early on list Make standard Position for thyroid . lectom ‘ operating surgeon 'V, Under supervision of Drapping should be composite so that they donot get displaced during procedure Incision should be planned so that it should neither fall on upper end of manubrium sterni_ nor. ascend very high Incision should extend from one border of sternocleidomastoid to other even if lobectomy is planned Flaps should be platysma deep Flaps should be raised up to adam's apple above and suprasternal notch below Sub -platysmal vein should be ligated both above and below Scanned with CamScanner