見習醫學生模擬手術教案

Teaching Plan of Simulative Surgery for Clerkship

目錄
壹、 術式名稱(Topic)： .................................................................................. 2

貳、 學習目標(Objectives of learning)............................................................ 2

參、 教學原則和方法(Principles and methods of teaching)........................... 2

肆、 概觀(Overview) ....................................................................................... 4

伍、 準備和器械(Preparation and instruments) ............................................. 5

陸、 步驟(Procedures) .................................................................................... 5

Midline incision ........................................................................................... 5

Exploratory laparotomy ............................................................................... 6

NG insertion .............................................................................................. 12

Wound closure of midline incision ............................................................ 12

McBurney's incision .................................................................................. 13

Kocher’s incision (Subcostal incision) ........................................................ 14

柒、 參考文獻(References) ........................................................................... 15

捌、 評量(Assessment of learning) ............................................................... 15

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壹、 術式名稱(Topic)：
Exploratory laparotomy and NG tube insertion

貳、 學習目標(Objectives of learning)
1. To know the surgical anatomy of abdominal wall and abdomen.
2. To know the choice of incision or surgical approach for laparotomy which influenced by the location
of possible pathology, presence of previous incisional scars and the operations planned.
3. To learn midline incision, Kocher’s incision and McBurney’s incision.
4. To learn thorough abdominal exploration.
5. To learn how to close the wound in layers.
6. To learn NG insertion in comatose patient and to know the actual location of NG tube in the
palpable stomach during laparotomy.

參、 教學原則和方法(Principles and methods of teaching)

1. Ask the students to prepare lessons, read handout, and review basic anatomy before class.
2. Pay respect to Silent Mentor in class.
3. Lead students to pray in silence before class (2 minutes).
4. Scan the abdominopelvic surface to see the body landmark, previous op scar or other
characteristics.
5. say the internal organs in the regions of abdomen by quadrants or 井( 3 by 3 grid)
6. Know the introduced incisions about indications and the layers of the wall.
7. Know each organ about its location, relation to the abdominal wall and organs surrounding
8. Know the skill of assisted fingers in the fauces (throat) in the insertion of NG tube.
9. Know the relation about the indwelled length marked at the site of tube which is fixed at nostril
orifice and location of functional fenestrated 10 cm of NG tube in the stomach.
10. Know the different indwelled length of NG between the indications of drainage and feeding.
11. Well practice the wound close layers by layers.
12. Approximation of skin by either absorbable material subcutaneously or non-absorbable Nylon in
interrupted simple, interrupted mattress or continuous ways.
⚫ Body surface of abdominal wall：bone prominent and muscular layer(下圖)

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⚫ Quadrants and layers of the abdominopelvic cavity (下圖) Anterior view.
The location of the organs of the abdomen and pelvis can be described by quadrant and layer.
Quadrants, defined by the intersection of the median plane and the transumbilical plane through the
L3 - L4 disk.

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肆、 概觀(Overview)
1. Terminology: exploratory laparotomy, incision
2. An exploratory laparotomy (also known as an ex-lap) is a surgical operation where the abdomen is
opened and the abdominal organs examined for injury or disease. It is the standard of care in
various blunt and penetrating trauma situations in which there may be multiple life-threatening
injuries, and in many diagnostic situations in which the operation is undertaken in search of a
unifying cause for multiple signs and symptoms of disease.
3. Indication: various blunt and penetrating trauma situations and diseases
4. Four elements are essential for a well-planned incision:
A. Accessibility 容易達到病灶處
B. Extensibility 傷口因需求易延展擴大
C. Preservation of function 保留腹壁構造功能(例如順著肌肉纖維紋理而不打斷肌肉)
D. Security 執行過程安全性高
5. Additional considerations in selecting the type of incision include:
A. Speed of entry 緊急時能以最快速度進入病灶
B. Certainty of diagnosis 針對特殊診斷需求
C. Body habitus 配合身體型態
D. Presence of previous scars 配合先前手術疤痕
E. Potential for problems with hemostasis 考慮出血控制及止血
F. Cosmetic outcome 美觀因素

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伍、 準備和器械(Preparation and instruments)
1. Should be performed in emergent conditions even without
Incisions of the neck, chest, and
informed consent or in selective condition with informed
abdomen. Key as follows:
consent or in scheduled operation after well explanation
A. Carotid incision
2. Gloves, Cap, Protective gown, Face shield, sterile drapes
B. Thyroidectomy incision
3. Chlorhexidine or Povidone iodine
C. Tracheotomy incision
4. Gauze pads
D. Subclavicular incision
5. Scalpel with No. 10 or 11 blade on a handle
E. Sternotomy incision
6. Suture or tying material 3-0 Nylon, 1-0 Vicryl
F. Infraareolar incision (either side)
7. Large curved Mayo scissor, suture scissor
G. Inframamary incision (either side)
8. Forceps, long smooth, teeth forceps
H. Clamshell incision
9. Gauze squares, 4 x 4 in (10)
I. Kocher / subcostal incision
J. Mercedes Benz incision
K. Paramedian incision (either side)
L. Chevron incision
M. Epigastrin / upper midline incision
O. McBurney's / Gridiron incision
(right side only - for appendectomy)
P. Rockey-Davis / Lanz incision
(right side only - for appendectomy)
Q. Supraumbilical incision
R. Infraumbilical incision
S. Pararectus incision
T. Maylard incision
U. Pfannenstiel / Kerr / pubic incision
V. Gibson incision
(either side, but conventionally left)
W. Midline incision
X. Inguinal incision
Y. Femoral incision
Z. Turner-Warwick's incision

陸、 步驟(Procedures)
⚫ Midline incision
Anatomic point:
1. Longitudinal incisions are often placed in the midline as minimal abdominal wall blood vessels
and nerves are located at the linea alba, thereby reducing the risk of significant vascular or nerve
injury. Additional advantages of the midline vertical incision are its ability to offer excellent
exposure to the entire abdomen and retroperitoneum, good extensibility, and easy entry. As the
midline incision provides the quickest entry, it is especially important for the unstable patients
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 with uncertain diagnosis.
2. Upper midline incision is aimed to explore the pathology limited in the upper abdomen such as
stomach, small intestine, colon and hepatobiliopancreatic lesions.
3. Low midline incision is aimed to explore the pathology limited in the low abdomen as
sigmoidorectal and pelvic lesions.
Procedures:

Midline incision (Adopted from Operative Anatomy, 3rd ed, LWW)

1. Make the skin incision from xiphoid to umbilicus and extend the incision across umbilicus down
to symphysis pubis if necessary.
2. Incise the linea alba with scalpel or electrocautery and enter the peritoneum by lifting up
bilateral fascia to avoid the injury of the intraperitoneal organs. (This maneuver creates negative
pressure in the abdomen. When the peritoneum is opened, air will enter the peritoneal cavity
and the underlying bowel will fall off the peritoneum.)
3. Extend the incision of peritoneum upward with caution not to tear the ligamentum teres and
downward with caution not to injury the urachus or urinary bladder. Alternatively, the urachus
can be incised and ligated.)
⚫ Exploratory laparotomy
Midline laparotomy provides a great opportunity to explore the entire abdominal organs. Do not
just focus on the pathologic site before carefully exploring the entire abdomen for unexpected
findings.
Sequence of systemic exploration of abdomen

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Exploratory laparotomy (Adopted from Operative Anatomy, 3rd ed, LWW)

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1. Start from spleen which fixed to left upper retroperitoneum, superiorly to diaphragm, inferiorly
to colon and kidney, and medially to pancreatic tail. Assess its size, hilar node, and presence of
nodules.
2. Then, palpate the esophagogastric junction and assess the hiatal size and the presence of hiatal
hernia.
3. Palpate and observe left lobe of liver first, then right lobe of liver and assess the presence of
cirrhosis or nodules.
4. Palpate and observe gallbladder and biliary tree and assess the presence of biliary stone, tumor
and the CBD diameter.
5. Palpate and observe the whole stomach, duodenum and pancreatic head and assess the
presence of ulcer, tumor, of stomach and duodenum, and tumor of pancreatic head.
6. Feel right kidney, palpate and observe ascending colon, cecum and appendix and assess the
presence of tumor, diverticulum and appendicitis.
7. Palpate and observe the transverse colon, especially both hepatic and splenic flexure and the
omentum and assess the presence of tumor, and metastatic nodes.
8. Feel left kidney, palpate and observe the descending colon, sigmoid colon and rectum and assess
the presence of tumor.
9. Palpate and observe the pelvic organs including the urinary bladder guided by Foley balloon,
uterus, ovaries and adnexa (in women) and assess the presence tumor and metastatic lesions
from GI tract (Krukenburg tumors or Blummer shelf).
10. Palpate and observe the entire small bowel and mesentery from Treitz ligament down to
ileocecal junction every 10-15 cm and assess the presence of diverticulum, tumor, and metastatic
nodules.
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 11. Finally, palpate the retroperitoneum and feel the aorta, common, internal and external iliac
artery and assess the presence of retroperitoneal metastatic nodes, atherosclerotic plaque and
aneurysm.
⚫ NG insertion
1. Estimate the length of NG by check the distance from nose to earlobe then turn to the Xyphoid
process.
2. Use finger put in the fauces to keep the tube attach to the side and help the tip to enter to the
esophagus.
3. Advance the tube to pass the GE junction and the other hand feel the location and movement of
the tube by pinching the gastric wall gently.
4. Feel the anterior end of 10 cm with holes pass fully through the GE junction, located in the
fundus or near the pylorus area.
5. Compare the actual length with the estimated length of insertion for both drainage and feeding.

⚫ Wound closure of midline incision

Anatomic points:
1. The midline wound should be closed layer by layer with caution not to suture the urinary bladder
at the low end.
2. The method of closure of the abdominal wall is a very critical aspect to avoid wound dehiscence.
3. Surgical closure of the peritoneum is unnecessary because of rapid reepithelization (< 48 hours)
and increase of advanced adhesion. But decrease the risk of adhesion of bowel to abdominal
wall.
4. The fascia is the most critical layer in wound closure since this tissue provides the greatest
wound tensile strength during healing. It may take several weeks to get adequate tensile strength
back, so a delayed absorbable or nonabsorbable suture for fascia closure is more preferred.
Don’t bite the muscle tissue as possible.

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 Wound Closure (Adopted from Maingot’s Abdominal Operation, 11th ed, MGH)
Incision Procedures:
1. The fascia closure can be completed with either a continuous or interrupted mass closure with
slowly absorbable suture (monofilament more favored) placed 1.5 cm from the fascia edge and 1
cm apart. The tissue should be re-approximated with low tension to prevent ischemia. And don’t
bite the muscle tissue but fascia and peritoneal membrane.
2. Alternatively, Smed-John fascia closure and retention suture can offer more wound tensile
strength to avoid wound dehiscence for those malnutritious or obese patients.
3. The skin incision can be closed with interrupted Nylon suture or staples.
⚫ McBurney's incision
Anatomic point:
1. McBurney’s point locates at outer third between the umbilicus and the anterior iliac spine.
2. McBurney’s incision is aimed to identify the lesions in appendix or cecum.
3. The internal oblique muscle and trasabdominis had better be splitted rather than transected.
4. Caution: The inferior epigastric artery which supplies the medial deep muscles may be
compromised if inferomedial wound is extended.

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 Procedures:
1. Make an oblique incision on the skin over the McBurney’s point.
2. The aponeurosis of the external oblique is incised parallel to skin incision.
3. The internal oblique, and transversus abdominis are separated by muscle splitting with Peants
and retracted lateromedially by army retractors.
4. The peritoneum and transversalis fascia are exposed and incised parallel to the skin incision.
5. The incision can be expanded laterally and upward, and medially if exposure is still not adequate.

McBurney’s incision (Adopted from

Maingot’s Abdominal Operation,
11th ed, MGH)

Wound Closure of McBurney’s incision:

1. Reapproximate the transverse abdominis and internal oblique muscle with interrupted
absorbable sutures.
2. 2.The aponeurosis of the external oblique muscle is closed with interrupted or continuous
absorbable suture.
3. 3.The skin incision is closed with interrupted Nylon suture or staples.
⚫ Kocher’s incision (Subcostal incision)
Anatomic points:
1. Right Kocher’s incision is indicated mainly for hepatobiliary surgery.
2. Left Kocher’s incision is indicated mainly for spleen and pancreatic tail surgery.
3. Extended (Bilateral) Kocher’s incision provides a great exposure for upper abdominal approach,
good extensibility for underlying pathology including liver, biliary tree, pancreas, stomach,
duodenum and spleen.
4. This incision will cut those tissues layer by layer from medial to lateral including anterior rectal
fascia and rectus abdominis, the external oblique muscle, internal oblique muscle, transversalis
abdominis, and posterior rectal fascia, fascia transversalis and peritoneum.
5. Superior epigastric artery located in deep muscle and more medially will be divided.
6. 8th thoracic nerve located inferomedially to 9th costal cartilage is inevitable to be divided.
7. Caution: 9th thoracic nerve should be well preserved. Injury of this nerve will denervate rectal
muscle.

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 Kocher’s (Subcostal) incision (Adopted from Maingot’s Abdominal Operation, 11th ed, MGH)
Procedures:
1. Make the skin incision 4 cm below costal margin long enough for underlying pathology.
Sometimes, extension crossing linea alba is needed.
2. Incise external anterior rectal fascia and external oblique muscle all the way with electrocautery.
3. Further cut rectus abdominis, internal oblique muscle and transverse abdominis and open the
peritoneum with scaple by lifting up fascia transversalis.
4. Extend the incision through posterior rectal fascia, fascia transversalis and peritoneum in the
plane of the skin incision.
5. Hemostasis is well done by electrocautery or ligature.
Wound closure of Kocher’s incision Procedure:
1. Continuously close the fascia transversalis, transversalis abdominis and posterior rectal fascia
with delayed absorbable suture.
2. Continuously close anterior rectal fascia, internal oblique, and external oblique muscle with
delayed absorbable suture.
3. Close the skin incision with Nylon or staples.

柒、 參考文獻(References)
1. Maingot's Abdominal Operations, 11th Edition (2006) Michael J. Zinner, Stanley W. Ashley
(Mcgraw-Hill) Chapter 4, Incisions, Closures, and Management of the Abdominal Wound
2. Operative Anatomy, 3rd Edition (2009) Carol E.H.Scott-Conner, David L. Dawson (Lippincott
Williams & Wilkins) Chapter 41, Exploratory Laparotomy
3. Gilroy Atlas, 3rd Ed.
4. https://en.wikipedia.org/wiki/Surgical_incision

捌、 評量(Assessment of learning)
1. Pre and post course writing test
2. Class performance
a. Attitude
b. Skill
c. Surgical landmark identification ability
d. Fluency and time control
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