72

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Surgicot Procedures lncluding Minimol Access Procedures

Abdominol Extrointestinol Surgery

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with a suture passed on a long instrument or by He-

Droping
Folded towels and a laparotomy sheet

rn-oclips, as is tle cystic duct. The gallbladder is mobiiir"a tv incising overlying peritoneumeand removed' . itt" .t"a""tying1iver bed may be reperitonealized' A

drain (e.g., Ja&son-Pratt)

exiting a *'o""ti and secured to the skin with a stitch' The "iuU is closed in layers. The skin is closed by interwound
m-ay be employed

Equipment Roll (for positioning)

Suction

rupted stitehes or skin staPles. bholangiogram. Perfoimed prior to the ligation of the cystic duct. A catheter is passedthrough the stump of thl cvstic duct into the common bile duct' A suture or specill cystic duct clamp secures the cath-eter' Prior io i"t ittg xlray films, all eitraneous metal clamps and retractors are removed from the field' The catheter is

Electrosurgical unit

X-ray cassette

lnstrumentotion Major procedures tray

Long Metzenbaum scissors Hemoclip appliers (various sizes and lengths) Biliary tract tray (for common duct exploration) Supplies Basin set Blades (1) No. 10, (1) No. 15 Hemoclips (various sizes) Electrosurgical pencil Needle magnet or counter

l".t"a *ittt

saline for leakage, and then radiopaque dy-e isl.tie"ted. X-rays are taken. The catheter is removed, andihe cystic duct is ligated. Choledochotomy ind Choledochoscopy' The common bile duct is exposed and traction sutures are oir."a through it' A longitudinal incision is made in the a viriety ofstone-removing forceps,scoops, and i".i, ""a irrigation and bailoon catheters may be empJoyed to exo-toi" fot and extract stones either proximally (hepatic Lile ducts) or distally (bile duct). A choledochoscope may U" employed. Further cholangiograms may then be "t.o taken. the duct is usually closed over a T-tube drain'

Drain (e.g., Jackson-Pratt)

T-tube (if choledochotomy is done)

Dissectors (e.g., peanut) Culture tubes (aerobic and anaerobic)

Preporotion of the Potient The patient is supine; both arms may be extended on armboards. Some surgeons position the patient with a roll under the right upper flank, which facilitates inierpretation of th-e cholangiogram,. "separating",the biliary tree from the spine. A preliminary x-ray film may be iaken to ensure correct placement of the cassette' Apply electrosurgical dispersive pad.
Skin PrePorotion

For Cholangiogram Catheter (surgeon's preference) and radiopaque

dye (e.8., HYPaque or Renografin 6o)

Small basins (2) for saline and'dye Biliary tract tray

Syringes (2) 30 mL

For Choledochoscopy
Choledochoscope

Begin at the incision, either right subc-ostal (most -frequintly used), right paramedian, or midline; extending ii'"* ttt" axiila to just above the pubic syrnphysis, and .down to the table at the sides.

Normal saline 1000 mL Flexible tubing (e.g., cystoscopy tubing) Polyethylene tubing (surgeons preference) Arterial line pressure bag