Traumatic pneumothorax

Under aseptic measure, local anesthesia using lignocaine and bupivacaine mixture was given. A
double chamber underwater deal was prepared with 300 ml. normal saline. Triangle of safety
identified on the right side of chest, 1cm long vertical incision given in 5th intercostal space anterior to
the mid-axillary line. A track made after the separation of skin and subcutaneous tissue. Track
palpated with index finger. Intercostal muscles were separated and pleural cavity reached while
noting a gush of air. A 28 French Chest tube introduced into the pleural cavity and fixed at the level of
12 mark. Wound stitched and sutured with silk suture after securing hemostasis. Air sealed, aseptic
dressing applied.

Ng

fter explaining the procedure and taking patient’s consent, 10 mL of viscous lidocaine 2% (for oral
use) instilled down the more patent nostril with the head tilted backward and the patient asked to sniff
and swallow to anesthetize the nasal and oropharyngeal mucosa. The length of insertion estimated
by measuring the distance from the tip of the nose, around the ear, and down to just below the left
costal margin. The patient positioned sitting upright with the neck partially flexed. The patient asked to
hold the cup of water in his or her hand and put the straw in his or her mouth. Lubricate the distal tip
of the NG tube. The NG tube was gently inserted along the floor of the nose, and advanced parallel to
the nasal floor. The patient was asked to sip on the water through the straw and start to swallow and
continue to advance the NG tube until the distance of the previously estimated length is reached.
Lastly, it is checked in position by the a deflating a 60cc syringe into the stomach via NG tube while
auscultating the air gush in epigastrium

acute appendicitis

Patient presented in ED with the history of Right iliac fossa pain for one day. It was initially present in
periumbilical area and now localized in RIF. O/E patient had a pulse of 90/min, temp of 99F.
Abdomen was tender in RIF. Rebound tenderness and guarding was also present. Patient had a TLC
count of 14.27 and CRp of 20. Open Appendectomy was planned. Under strict ASM, a grid iron
incision was made. Incision was deepened through the subcutaneous tissue. External oblique
aponeurosis divided. Internal oblique and transversus abdominis muscle splitted. Peritoneum
identified and lifted and divided. Purulent fluid was present in the peritoneal cavity. Culture was taken.
Appendix identified which was gangrenous at it's tip. Mesoappendix was identified, ligated and
divided. Base of appendix was crushed, ligated and divided. Hemostasis secured. Abdomen closed in
reverse order. Skin closed with Vicryl Rapid in subcuticular fashion. Aseptic dressing done

.Reversal mucous fistula

Patient was known case of adenocarcinoma of recto sigmoid junction. Anterior resection of tumor
was done and Hartman procedure was done. After clearance of cancer, reversal of mucous fistula
was planned. Under asm, exploratory laparotomy done. Mucous fistula mobilized. Distal
rectal stump identified. Circular stapler 32 used for anastomosis. Doughnuts of tissue after
stapler anastomosis were carefully examined. Asd done
MNG
Under ASM, Kocher’s collar incision given. Flaps raised. Strap muscles separated. Thyroid gland
mobilized. Superior Thyroid Pericles ligated then RLN and parathyroid identified and spared. Total
thyroidectomy done. Drain placed. Skin closed. Asd done

Cancer testis

Patient presented with para-aortic lymph nodal mass in abdomen. Bhcg and ldh levels were raised.
Testis was enlarged and hard. So orchidectomy was planned.

Under ASM, oblique incision given 2 cm above inguinal ligament. Subcutaneous tissue and fascia
dissected. External oblique cut. Spermatic cord identified. Inguinal orchidectomy done. Asd done.

Hydrocele

Under ASM, transverse incision given over right scrotum. Dissection done layer by layer. Fluid
drained from hydrocele and jabouley’s repair of hydrocele done.

incarcerated incisional hernia

Patient presented in surgical emergency with history of hypogastric swelling and pain since 1 day. No
associated vomiting or constipation. On examination swelling was present above the previous
pfenential's incision measuring 3x7cm. Tender to touch, irreducible, cough impulse was present.
Bowel sounds were audible. CT showed incarcerated incisional hernia. Under Strict aseptic
measures, a transverse incision was made over the hernia defect. The incision was deepened into
the subcutaneous tissue and till anterior sheath. Dissection was done along the anterior sheath till the
neck of the sac was reached. Sac was opened. Viable omentum was present which was reduced.
Facial defect was closed by double-breasted primary repair using prolene. An onlay mesh was placed
over the defect and anchored to anterior sheath. A suction drain was placed. Skin closed with prolene
2/0. Aseptic dressing done.

VARICOSE VEINS

Patient presented in OPD with history of right sided vericose veins and incompetent sephanofemoral
junction. Lipodermoscelrosis was present. US Doppler showed no evidence of vericose veins and
SFJ was incompetent. Under strict aseptic measures, an incision was made 1cm below and 2cm
lateral to pubic tubercle. The incision was deepened through the subcutaneous fat and then through
the scarpa's fascia exposing the sephanofemoral junction. The juction was dissected proximally and
distally till the exposure of all the tributries. The long sephanous vein and common femoral veins were
clearly identified. Multiple tributries to long sephanous vein and sephanofemoral junction were ligated
and divided. The long sephanous vein was divided between artery forceps and transfixed flush with
the femoral vein. A short incision was made in the distil thigh and sephanous vein was exposed. Vein
stripper was introduced through the Sephanous Vein and retrieved through the incision made at distil
thigh after making a venotomy. The proximal end of the vein was tied to stripper and distil end was
ligated and divided. The stripper was pulled down to avulse the vein. Residual varices were avulsed
through a series of small incisions. Subcutaneous tissue was closed with vicryl 2-0 and skin with
prolene 2-0. ASD done. Compression stockings applied

Gall Bladder Polyps

Patient presented in OPD with history of 3 gallbladder polyps measuring 1cm. She was booked for
Laparoscopic cholecystectomy. Under strict aseptic measures, pneumoperitoneum was achieved
using veress needle. 10mm port was inserted at umblicus. 2 further incisions were made at
epigastrium(10mm) and in the right mid clavicular line and ports inserted. Diagnostic laproscopy was
done. Multiple adhesions surrounding the gallbladder were divided. Gall bladder was lifted with the
help of grasper at the hartmann's pouch. Peritoneum over the neck of gallbladder was divided. Calot's
triangle was identified and dissected. Critical view of safety was achieved. Cystic duct and artery
identified ligated and divided. Gall bladder was dissected off the gall bladder bed. Haemostasis was
achieved. Gall bladder retrieved from the epigastric port. Anterior sheath at the umblical port sutured
using vicryl 1/0. Skin closed with prolene 2/0. ASD done

Rectal Perforation

Patient was admitted under gynae/obs department for hysteroscopic excision of

submucosal fibroid 5 days ago. Now presented with Abdominal pain and distension. O/E
tenderness and rebound tenderness of the abdomen was present. Bowel sounds were
absent. CRP was 324, WCC was 7.09. CT Scan showed free air in the abdomen. Exploratory
Laparotomy was done. About 500 ml of fecal matter was present in pelvis. A perforation of
about 2x3 cm was present in posterior wall of uterus and anterior wall of rectum.
Hartmann's procedure was done. Sigmoid colostomy made. Abdomen closed in reverse
order after securing hemostasis and placing wide bore drains. Skin closed with Nylon.

SIGMOID VOLVULUS

Patient presented in ED with history of absolute constipation and vomitting for 4 days. Xray showed
coffee bean sign. CT Scan showed sigmoid volvulus. After resuscitation, patient was taken to OR for
endoscopic decompression of Sigmoid Volvulus. Patient was planned for elective sigmoidectomy
after successful endoscopic decompression.

WART ON CHEST

Patient presented in OPD with history of warts and chest. under strict aseptic measures, excisional
biopsy done and sent for histopathological analysis. Skin closed with vicryl 4/0 rapide. Aseptic
dressing done

WART PERIANAL WITH ANAL STENOSIS AND PERIANAL FISTULOUS TRACT

Patient presented in OPD with history of perianal pain and anal incontinence. On
examination, there were perianal warts with anal stenosis and multipuls perianal fistulous
tracts through which fecal matter was coming. Under strict aseptic measures, excisional
 biopsy done and sent for histopathological analysis. Diversion colostomy done. Skin closed
with vicryl 4/0 rapide. Aseptic dressing done.
Later biopsy proved squamous cell carcinoma of anal canal

Fire arm abdomen nephrectomy

Patient presented in surgical emergency with history of firearm injury about 30 minutes ago. On
examination he had an wound on left lumbar region. He had vitals of Pulse=120/min, B.p of 90/60,
temp of 98F and Resp Rate of 24/min. On abdominal examination , diffuse tenderness was present
rebound tenderness was also present. Bowel sounds were present. After taking 2 large bore IV lines
and resuscitation of patient was started and patient catheterized. Gross hematuria was present.
Decision to explore the patient was made and patient was shifted to OT. Under strict aseptic
measures, a midline laparotomy incision was made. On exploration, a single perforation was present
about 2 feet distil to DJ and grade 5 renal injury was present. Subsequently left nephrectomy was
done after doing an ontable sigle shot IVP. Resection anastomosis of jejunum was done. Hemostasis
was secured. A pelvic drain was placed. Abdomen closed in reverse order. Aseptic dressing done

Tb abdomen
Patient presented in surgical emergency with history of abdominal distension, absolute constipation
and vomiting for 3 days. There was history of evening pyrexia however no weight loss was present.
On examination her pulse was 101/min, temp was 99F, respiratory rate was 20/min and Bp was
100/60. Her abdomen was distended with generalized tenderness. Rebound tenderness was not
present. Bowl sounds were exaggerated. X rays revealed multiple airfluid levels in jejunum.
Ultrasound was unremarkable. Patient was resuscitated however after no improvement patient was
explored through midline laparotomy incision. Upon exploration grossly distended jejunum was
present with 2 strictures in ileum, about 3 and 3.5 feet proximal to icj, multiple mesenteric lymphnodes
were also enlarged. Resection of the strictured segment was done and end to side ileoileal
anastomosis done. Lymph node biopsy was taken. Hemostasis was secured and abdomen closed in
reverse order. Aseptic dressing done

Enteric perforation
Patient presented in surgical emergency with the history of fever for 1 month and now abdominal
distension and absolute constipation for 3 days. On examination patient had a pulse rate of 110/min,
b.p of 100/60, respiratory rate of 24/min and temperature of 101F. On abdominal examination, diffuse
tenderness was present and abdomen was tense and having board like rigidity. Bowel sounds were
absent. Liver dullness was obliterated and Shifting dullness and fluid thrill was also present. DRE was
unremarkable. Patient was resuscitated. Chest xray showed air under diaphragm. TLC count was
15000. Patient was explored through midline about 1litre of purulent fluid was present, abdominal
lavage was done with 9 litres of warm saline. A perforation was present about 5cm proximal to ICJ.
Perforation was repaired and a loop diverting ileostomy fashioned in right iliac fossa about 1 feet
proximal to the perforation. A pelvic drain was placed and after securing hemostasis, abdomen closed
in reverse order. Aseptic dressing done

Open cholecystectomy

Patient presented in surgical emergency with history of right hypochondrial pain for 3 days along with
multiple episodes of vomitting. Upon examination, patient had a pulse of 88/min, temp of 98F Blood
pressure of 120/60 and respiratory rate of 22/min. A mass was palpable in right hypochonrium with
moved little with respiration. Murphy's sign was positive. Ultrasound abdomen revealed gallbladder
wall thickness of 6mm and pericholecystic fluid. Tlc count was 12000. Patient was initially admitted
and managed conservatively however on 3rd post admission day her pulse rate increased to 101/min
with multiple episode of high grade fever. Guarding and rigidity was present in right hypochondrium.
Patient was explored through kocher's right subcostal incision. Omentum, colon and stomach was
badly adherent to gallbladder. Adhesiolysis was done which revealed concealed perforation of gall
bladder and empyema gall bladder. Calot's triangle was frozen and thus a reconstitutive subtotal
cholecystectomy was done after extration of 2 stones which were impacted at hartmann's pouch.
Hemostasis was secured and a subhepatic drain placed. Abdomen closed in layers.

Blunt Trauma to Abdomen(hit by a bull)

Patient presented in surgical emergency with history of blunt trauma to abdomen about 12 hours
ago. He was hit by a bull. Upon presentation he had a pulse of 120/min, blood pressure of 90/60,
temp of 100F and respiratory rate of 25/min. Patient was managed according to ATLS protocols and
resuscitated. Upon abdominal examination, diffuse tenderness, guarding, rigidity and rebound
tenderness was present. Bowel sounds were absent. He has a Hb of 16 and TLC of 16000. Patient
was explored through midline. About 2 litres of fecopurulent material was present and jejunum was
transected about 2.5 feet distil to dj flexure. About 1 feet of gut was resected and primary
anastomosis done with vicryl 3/0 in single layer extramucosal fashion. Abdominal lavage done. A
pelvic drain was placed hemostasis secured and abdomen closed in reverse order. Aseptic dressing
done.

Acute Mesenteric Ischemia

Patient presented in surgical emergency with history of pain in abdomen for 3 days along with
absolute constipation following an episode of melena. On examination he had a pulse of 100/min,
temperature of 99F, respiratory rate of 20/min and Blood pressure of 130/60. On abdominal
examination, generalized tenderness and guarding was present. Bowel sounds were absent. DRE
revealed normal anal tone but collapsed rectum. Xray abdomen revealed multiple airfluid levels and
TLC count was 20000. Patient was a known smoker for last 20 years and had previously experienced
similar episodes of pain almost 1 hour after eating meals. No other co morbidities were present
0Despite resuscitation, patients symptoms and signs didnot improve so patient was explored
through midline. Upon exploration about 3 feet of jejunum was found to be gangrenous about 2
feet distil to DJ flexure. Pulses in the mesentry of gangrenous segment were found to be absent.
Rest of the gut was examined and found to be viable. Stomach, liver, spleen and pancreas had no
gross pathology. Resection of the gangrenous gut was done till the viable bleeding margins were
achieved and anastomosis performed in single layer interrupted fashion with vicryl 3/0. A pelvic
drain was placed and patient heparinized intraoperatively. Hemostasis was secured, tension
releiving stitches were applied. Aseptic dressing done. Resected segment was sent for
histopathology and patient anticoagulated with clexane 60mg BD.
Simple Multinodular Goitre

Patient had a history of swelling in front of neck for 3 years. Clinically she was euthyroid. TFTs were
within normal range. Ultrasound neck revealed a multinodular goitre. FNAC revealed colloid nodule.
Total thyroidectomy of the patient was planned. Under stict aseptic measures, a kocker's collar neck
incision was made and subplatysmal flaps were raised. Median raphe was identified and divided.
Strap muscles were retracted and left love of thyroid gland was delivered from the wound. Middle
thyroid vein was identified, ligated and divided. Superior pole was identified, superior thyroid artery
and vein was ligated and divided near the upper pole. Inferior thyroid vein was idenfied , ligated and
divided. Recurrent laryngeal nerve and Parathyroids were identified and preserved. Tertiary
branches of inferior thyroid artery were identified, ligated and divided. Similar steps were repeated
on the right side. 1 suction drain was placed after securing hemostasis. Median raphe was
approximated. Subcutaneous tissue approximated. Skin closed with prolene 2/0(subcuticular
stitches applied).

Colostomy(perianal wound following RTA)

Patient presented in Surgical emergency following RTA which resulted large perianal wound.
To prevent soiling diversion end colostomy was made followed by split thickness skin
grafting by plastic surgery department. Later on DRE showed anal stenosis for which
dilatation was done. After confirming normal anal tone and diameter, patient was planned
for reversal. Under strict ASM, a perstonal ellipitical incision was made. Proximal stoma was
mobilized. Distil stump of transverse colon was identified and refreshed. A single layer
extramucosal anastomosis was fashioned between the proximal and distil end. Hemostasis
secured and abdomen closed in reverse order. Aseptic dressing done. Patient's recovery was
uneventful and he was discharged on day 5 of procedure while tolerating semisolids.

Choledocholithiasis + Cholelithiasis

Patient presented in OPD with history of ERCP and stent placement for CBD stones. Follow up
ultrasound showed a stone in CBD measuring 12mm. CBD exploration was planned. Under strict
ASM, Kocher's incision was made, anterior rectus sheath and rectus muscle divided. Posterior
sheath and peritoneum incisied. Cholecystectomy was done. Duodenum was kocherized. 2 stay
sutures with vicryl 3/0 were placed on CBD and choledochotomy measuring 1 cm was made
vertically. Desjarden's forceps was used to extract the stone and stent which was embeded in the
mucosa of CBD rest of CBD and hepatic ducts were found to be clear. CBD was closed over t-tube.
Subhepatic drain was placed. Hemostasis secred and abdomen closed in reverse order.

Duodenal Ulcer Perforation

Patient presented in surgical emergency with history of Absolute constipation, abdominal

distension and abdominal pain. Patient was known smoker and had long history of GERD. On
examination his pulse was 110/min, B.p was 90/60, temp= A/F, R/R=28. Abdomen was
tense, tender, guarding and rebound tenderness was also present. X-rays showed air under
diaphragm. Patient was explored through upper midline laparotomy incision. There was a
perforation present in first part of duodenum measuring 1x 1cm along with 1 litre of bilious
fluid in abdominal cavity. Abdominal lavage was done with 7 litres of warm saline. Graham's
omentopexy was done. Hemostasis secured. Subhepatic drain was placed. Abdomen closed
in reverse order. Aseptic dressing done.

Adhesion Obstruction

Patient presented in surgical emergency with history of absolute constipation for last 8 days
she was referred from DHQ Okara. X-rays showed multiple air fluid levels. There was
previous history of myomectomy. Patient was explored through midline laparotomy
incision. A band was found arising about 1.5 feet proximal to ICJ. Band was released. A
strictured portion of terminal ileum was present stuck in the band. The stricture was
negotiable. Rest of the gut, liver, pancreas and spleen were alright. Abdomen closed in
reverse order. Aseptic dressing done.

Perforated Appendix

Patient presented in surgical emergency with history of pain in right ilac fossa and vomiting
for 1 day. On examination he had a pulse of 110/min, blood pressure of 110/60, respiratory
rate of 21/min and temperature of 100F. His abdomen was tender in right iliac fossa and
rebound tenderness was also present. Rovsing sign and obturator signs were positive.
Patient was explored through grid iron incision. Appendix was perforated at tip of appendix.
Mesoappendix was identified ligated and divided. Base of appendix was crushed, ligated and
divided. Peritoneal toilet was done. Abdomen closed in reverse order. Skin was left open.
Aseptic dressing done.

Blunt Trauma Abdomen(Grade V Splenic Injury)

Under strict aseptic measures, midline laparotomy incision made, lina alba incised,
peritoneum breached. About 1.5 litres of hemoperitoneum was present. Grade 5 splenic
injury was present with avulsion of splenic vessels. Spleen was delivered through the wound
and splenic hilum clamped while making sure that pancreatic tail is preserved. Splenic artery
and vein were ligated and divided. Short gastric vessels were ligated and divided. Lienorenal
and splenocolic ligaments were already avulsed. Rest of the gut, liver and pancreas were
examined. No other injury was present. Left subphrenic drain was placed after securing
hemostasis. Abdomen closed in reverse order. Aseptic dressing done.

Strangulated Paraumbilical Hernia

Patient a known case of CLD presented with abdominal hernia for last 5 years. It had
become irreducible for last 10 days. Vomitting, absolute constipation and abdominal
distension was present for last 3 days. TLC was 18000 and Xray showed multiple air fluid
levels. Patient was explored through transverse incision. Hernial sac was identified and
 dissected free off the surrounding fat. Hernial sac was opened about 500ml of pus and
ascitic fluid was present along with gangrenous ileocaecal junction. Liver was grossly
cirrhotic. Limited right hemicolectomy was performed and exteriorized. Defect was repaired
primarily and gangrenous fat was debrided tension releiving sutures were applied. Aseptic
dressing was done.

Autoimmune Hemolytic Anemia(Lap Splenectomy)

Patient presented in OPD with history of autoimmune hemolytic anemia. After buidling up
hemoglobin of the patient and vaccination of patient 2 weeks prior to operation laparoscopic
splenectomy was planned. Under strict aseptic measures, patient was positioned in semi prone
lateral position and 4 port incision was made. Splenocolic ligament was divided and dissection
contiued laterally upwards taking down lateral attachments and splenophrenic ligament.
Gastrospenic ligament along with short gastric vessels were ligated and divided. Lienorenal ligament
was dissected and spleen mobilized medially. Splenic artery and splenic vein were skeletonized and
individually ligated and divided. Spleen was crushed with the help of sponge holder forceps and
delivered in endobag through the supraumbilical port. Left subphrenic drain was placed after
securing hemostasis. Anterior sheath was closed. Skin closed with prolene 2/0. ASD done.

Acute Cholecystitis (Interval Cholecystectomy)

Patient presented in surgical emergency with history of pain in right hypochondrium and
fever for 5 days. Ultrasound revealed gall bladder wall thickness of 5mm and pericholecystic
fluid. TLC count was 15000. Patient was managed conservatively and followed up for
interval cholecystectomy. Under strict aseptic measures, 3 port incision was made and
pneumoperitoneum achieved. Calot's Triangle was dissected and cystic duct and artery
skeletonised. Cystic artery was ligated and divided. Cystic duct was ligated and divided.
Gallbladder was dissected off the gallbladder fossa. Gallbladder was retrieved through the
epigastric port. Hemostasis was secured and anterior sheath approximated was vicryl 2. Skin
closed with prolene 2/0.

Mesenteric Ischemia

Patient presented in surgical emergency with history of abdominal pain and distension. On
examination patient was tachycardiac and hypotensive. Abdomen was distended,
tenderness out of proportion and bowel sounds were absent. Ecg showed atrial fibrillation.
Xrays showed pneumonitis intestinalis. TLC count was 25000 and NG aspirate showed coffee
ground aspirate. Patient was explored, 300ml of purulent fluid was found and whole of the
small gut uptill medial 2/3rd of transverse colon was found to be gangrenous. Abdomen was
closed after securing hemostasis with tension releiving sutures. Aseptic dressing done.

Perianal Fistula

Patient presented with history of perianal discharge for 6 months. Examination showed an external
opening at 6 o clock position about 1cm from anal verge. DRE revealed internal fibrosis at 6 o clock
position. Fistulogram showed a perianal fistula at 6 o clock position Under strict ASM, examination
was done under anasthesia. Tract was probed. A low lying fistula was present at 6 o clock position
which was layed open. Wall biopsy of tract was taken. Tract was curettaged and packed with guaze
piece.

Hurthle Cell Carcinoma Of Thyroid

Under strict ASM, kocher's collar neck incision was made 2cm above the suprasternal notch. Incision
was deepened till subplatysmal plane and flaps were raised till thyroid cartilage superiorly and
suprasternal notch inferiorly. Median Raphe was divided and strap muscles were retracted. A mass
of about 2x2cm was present in right robe encasing the recurrent laryngeal nerve. Total
thyroidectomy was done and the mass was shaved off the recurrent laryngeal nerve. Another mass
of about 5x 3 cm was present in lateral aspect of neck on the right side which was adherent to
sternocledomastoid and internal jugular vein. Modified Radical neck dissection of type 1 was done.
Sternomastoid, mass and the IJV were removed enbloc. Phrenic nerve, brachial plexus and Spinal
accesory nerve along with cervical plexus deep to prevertebral fascia were preserved. Hemostasis
was secured and 2 suction drains were placed. Strap muscles were approximated and wound closed
in reverse order. Aseptic dressing was done. Postoperatively both the vocal cords were mobile.

CA Hypopharynx

Patient was referred from ENT department. She was a known case of advanced CA
hypopharynx. Due to dysphagia feeding gastrostomy was planned. Subsequently stamm's
gastrostomy was performed through upper midline incision and patient was reffered back to
parent unit for further management.

Stamm's Gastrostomy

Duodenal Ulcer Perforation

Patient was admitted in ward following Graham's Omentopexy which was done in emegency
for duodenal ulcer perforation. On 5th post op day, bilious discharge was seen to come out
of her wound and subhepatic drain. Patient was becoming toxic (Pulse=112/min ,
B.p=90/60, Temp= 101F, TLC = 18000). After resuscitation patient was explored electively.
There was a leak present from previous repair and multiloculated collections were present
in paracolic gutters and pelvic region. Abdominal lavage was done. T-Tube duodenostomy
was done along with feeding jejunostomy. After securing hemostasis and placing a widebore
subhepatic and pelvic drain, tension releiving sutures were applied and patient shifted to
ICU.

Sigmoid Volvulus

Patient presented in surgical emergency with history of Absolute constipation, abdominal distension
and vomiting for 3 days. He had episodes of constipation previously as well which were relieved by
laxatives. On examination his pulse was 100/min, blood pressure was 100/60. Respiratory rate was
25/min. His abdomen was distented, diffusely tender. Rebound tenderness was not present. Digital
rectal examination was done which revealed ballooning of rectum. Xray showed coffee bean
appearance of gut loop. TLC was 15000. Patient was explored through midline. Sigmoid volvulus was
present. Sigmoid was twisted in anticlockwise fashion. Sigmoidectomy and double barrel colostomy
was performed. Hemostasis secured and abdomen closed in reverse order.

Spindle Cell lesion of Forearm

Under strict ASM, local anesthesia was infilterated around the lesion present 5cm proximal to wrist
joint. Lesion measured 5x3cm. It was mobile, tender, normothermic, non fluctuant. An elliptical
incision was made. Perilesional dissection was done and lesion was excised. Skin approximated with
prolene 2/0 after securing hemostasis.

Intestinal Obstruction

Under strict ASM, midline laparotomy incision was made. Incision was deepened through
subcutaneous tissue and linea alba. Peritoneum was breached. Abdomen explored.
Strictured Ileum was adherent to the wall of urinary bladder about 1 feet proximal to ICJ
however no fistulous communication was present between ileum and bladder. Resection of
ileum was done and Ileostomy made in Right iliac fossa. Resected gut was sent for
histopathology. Abdomen closed in reverse order. Skin closed with prolene 2/0. Aseptic
dressing done

Loop Colostomy(Hirschsprung disease)

Under strict ASM, a peristomal elliptical incision was made about 2mm from the mucocutaneous
junction and deepened into the subcutaneous tissue till the anterior sheath. The attachments to the
anterior fascia were carefully divided circumferentially. Peritoneal cavity was entered and any
adhesions with the loop were divided for complete mobilisation of loop. Anterior layer of stoma was
closed in single layer extramucosal fashion with vicryl 3/0. Hemostasis was secured. Abdomen
closed in layers.

Sebaceous Cyst left thigh

Under strict aseptic measures, an elliptical incision was made over the swelling including the
punctum in it. A plane was created between the cyst wall and surrounding subcutaneous tissue.
Sharp dissection was done in this plane and cyst was excised. Skin closed with prolene 2/0. ASD
done

Invasive ductal Carcinoma Right Breast

Under strict aseptic measures an elliptical incision was made on right breast including the nipple
areola complex in it. Skin flaps were raised superiorly till the subclavius and inferiorly 2cm below the
inframammary fold. Dissection was carefully done along the cooper's fascia. Breast tissue along the
mass was dissected off the pectoral fascia. Axillary dissection was started after the identification of
axillary vein. Level 2 dissection of axillary nodes was done while preserving the long thoracic and
thoracodorsal neurovascular bundle. 2 suction drains were placed 1 for flap and another for axilla
after securing hemostasis. Subcutaneous tissue was approximated with vicryl 2/0. Skin closed with
prolene 2/0. Aseptic dressing done.

Right Inguinal Hernia

Under strict aseptic measures, right sided suprainguinal incision was made. Camper's and scarpa's
fascia was divided to expose the external oblique aponeurosis. A small incision was made in the
external oblique aponeurosis and metzenbaum scissors were introduced through it and spread.
External Oblique aponeurosis was divided along the line of fibres and external ring was divided.
Ilioinguinal nerve was identified and preserved. External oblique flaps were seperated bluntly from
the underlying internal oblique muscle. Pubic tubercle was identified and cord structure were lifted
off the pubis. Cremesteric muscle encircling the cord were divided along the line of it's fibres. An
indirect sac was found which was sharply dissected off the cord. Sac was opened. It contained viable
omentum which was reduced. Sac was suture ligated near the deep ring and amputated. Lipoma of
cord present was excised. A mesh of 6 x 11cm was placed and affixed to anterior rectus sheath
medially to overlap pubic tubercle. Fixation was continued on the inguinal ligament from medial to
lateral direction. The upper end of the tail was was fixed to internal oblique aponeurosis.
Hemostasis was secured. External oblique aponeurosis approximated. Subcutaneous tissue
approximated using vicryl 1. Skin approxiamated using prolene 2-0. Aseptic dressing done

Perianal Fistula

Under strict aseptic measures the external opening of the fistulous tract was identified. (At 11 o
clock position). Povidon Iodine was injected through this opening to identify the internal opening(11
o Clock) which was present high above the dentate line. A probe was passed through external
opening and it's end retrieved through internal opening. Small pocket of pus was drained.
Seton(Prolene 1) was passed through the opening and loosely tied. Anal Canal packed with guaze
piece

Spontaneous Pneumothorax

Under strict aseptic measures, triangle of safety identified. Local anaesthesia given at the incision
site. Incision made at 5th intercostal space in anterior axillary line. Incision deepened to
Subcutaneous tissue. Intercostal muscles were splitted till the pleural cavity was opened. Gush of air
was seen to come out. Finger was inserted into the cavity to dilate it and to break the adhesions.
Care was taken to create a tract at the upper border of 5th rib. A 28 F chest tube was inserted
towards the apex. Drain was connected to underwater seal. A purse string suture was applied and
the drain anchored with Silk 1. Aseptic dressing was done.
Gastric Outlet Obstruction

Under strict Aseptic measures midline laparotomy incision was made. Incision was
deepened through linea alba and peritoneum breached. Stomach and first part of
duodenum were inspected. Dense scarring was present in pylorus and first part of
duodenum. A Roux en Y handsewn gastrojejunostomy was fashioned. An
enteroenterostomy was made with stapler about 60cm from DJ flexure. Gall bladder
contained a single calculus. Subsequently a retrograde cholecystectomy was done due to
scarring at calot's triangle(previous Duodenal ulcer perforation). Lymphnode of Lund was
enlarged and it's caseous necrosis was present. It was excised and sent for histopathology
Hemostasis was secured. A subhepatic drain was placed and abdomen closed in reverse
order. Skin closed with prolene 2/0. Aseptic dressing was done.

3rd Degree Haemorrhoids

Under strict aseptic measures, artery forceps was applied to skin element of each
haemorrhoid and second artery forceps was applied to prolapsing mucosa. Excision of first
haemorrhoid(3 o clock position) was with a V-shaped incision through the skin at the base of
external component. The dissection was further deepened under the 'V' to develop thel
plane outside the haemorrhoidal tissue, while making sure that dissection was within the
internal sphincter. Haemorrhoidal tissue was dissected off the underlying sphincter up into
the anal canal till it remained attached with a small pedical containing the feeding vessels of
plexus. The pedical was transfixed and haemorrhoidal tissue excised. Same procedure was
repeated to haemorrhoid present at 11 o clock position. Anal canal was packed with guaze
piece after securing hemostasis.

Obstructed Right inguinal Hernia

Under strict Aseptic measures J shaped incision was made. Incision deepened through the
subcutaneous tissue. External Oblique aponeurosis incised along the direction of it's fibres.
Superfiscial ring opened. Sac seperated from the cord structures. Sac opened. About 30ml of
reactionary fluid was present along with gut which was dusky in color. Gut was packed in
warm saline soaked sponge. Mesenteric vessels had good pulses. Peristalsis were present.
Gut regained it's normal color and was reduced after it's viability was confirmed. Sac was
closed with pursestring suture. Desarda's repair was done and abdomen closed in reverse
order. Skin closed with prolene 2/0. Aseptic dressing done.

Blunt Abdominal Trauma(Spleen hilum rupture)

Under strict aseptic measures, midline laprotomy incision was made, incision was deepened through
the subcutaneous tissue till linea alba. Linea alba divided and peritoneum breached. About 1.5 litres
of gross blood found. All four quadrants of abdomen along with pelvis packed. Upon removal of
packs, blood was seen coming from the hilum of spleen. The left peritoneal leaf of the lienorenal
ligament was incised, spleen was dislocated forwards and it's vascular pedicle was compressed
between finger and thumb. The tail of pancreas was identified and and seperated from hilar vessels
and splenic artery was clamped and ligated. Splenic vein was clamped and ligated seperately. Spleen
was further mobilized by taking down the splenic flexure and dividing the gastrosplenic ligament
after ligating and dividing the short gastric arteries and the left gastroepiploic vessels. Phrenosplenic
ligament was divided and spleen delivered through the wound. Rest of the abdomen was inspected.
Liver, stomach, large and small bowel and mesentry were found to be normal. Abdomen was closed
in layers. Skin approximated with prolen 2/0. Aseptic dressing done

Meleney's Gangrene

Under strict aseptic measures Dead nectrotic skin on the abdomen was excised.
Debridement done till bleeding of the skin edges and soft tissues seen. Wound washed with
copious amount of saline. Aseptic dressing done.

Recurrent Pleomorphic Adenoma

Under strict aseptic measures, a lazy S incision was made. The incision was deepened through the
platysma until the surface of parotid fascia was reached. Greater auricular nerve was identified and
divided near the parotid gland. Sternocleidomastoid was retracted laterally to expose the posterior
belly of digastric muscle, which was followed till the mastoid process. The tragal pointer was
identified and dissection done 1cm below and medial to it. Facial nerve was identified. The gland
was carefully dissected off the facial nerve and it's upper and lower divisions using bipolar and sharp
dissection. Hemostasis was secured and wound was closed over the suction drain with seperate
closure of platysma and skin.