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com Colorectal Operative

Preparation for all colonic surgery:
Colonoscopy: Exact site and Gross description, Tissue diagnosis, tattooing if small (eg. polyp),
and for synchronous lesions.
Tumor Markers: preoperative baseline CEA, and Preoperative Stoma Marking
CT: Staging and assess local invasion, Assess need of Preop Ureteric stent.
Tumour Board.
Informed Consent, Nutritional Status, Blood standby, Antibiotics, Follys, IVF, DVT prophylaxis,
Colon Prep (Usually not needed)
Position of the patient, and make sure all your instruments (Staplers, Energy devices, stoma
appliances) are available before procedure.
Keep in mind the hospital setting your working one, if in a peripheral hospital where you no
support , do the minimum eg. diverting stoma in obstructing sigmoid cancer.
Remember to refer rectal cancer and recurrent colon cancer to a colorectal surgeon.
Remember the hospital settings you are working in, e.g. if in a peripheral hospital alone with no
support the safest option is to do diverting stoma in an obstructed sigmoid mass and send to a
more advanced hospital.
In emergency obstructed colonic masses don't forget to assess the rest of the colon for any
synchronous lesions either intraop or post operatively as soon as possible.
Right Hemicolectomy:Principles:
Right Hemi : Ligate right colic, and right branch of middle colic.
Extended Right Hemi: ligate both right colic and middle colic.
10 cm of ileum will be resected due to common blood supply with cecum.
No touch technique: is to start by ligating the lympovascular pedicle (iliocolic and middle colic)
before attempting to mobilise or touch the tumour. (NO superior Oncological results). (Can be
called Medial to lateral Approach), as compared to lateral to medial approach (described below).
Oncological Resection is to include the lymph nodes draining segment along the vascular supply
enbloc with the tumour.
The adequate safe margin in colon malignancy is 5 cm proximal and distal with 12 lymph nodes.
If the tumour in the hepatic flexure you need to resect the proximal two thirds of the transverse
colon along WITH the greater omentum attached to it.
If the tumour is in the cecum you don't need to take any omentum.
Procedure: (Lateral to medial)
Supine Position under GA and Midline laparotomy
Explore all the abdomen and palpate the liver and rest of the colon (in emergency)
Retract the colon medially Start mobilizing along the white line of Toldt.
Identify the ureter (crossing the common iliac artery), Duodenum and the gonadal vessels.
Continue with hepatic flexure mobilization, and avoid excessive traction on the duodenum.
Dissect distally through the gastrocolic ligament is encountered and dissect through the it.
Once the lesser sac is opened, the gastrocolic ligament is divided from left to right
once colon fully mobilized, identify the lymphovascular pedicles by retracting the small bowel to
the left side to expose the root of the mesentery
The ileocolic vessels are located at the caudal portion of the root of the mesentery.
Identify the superior mesenteric artery to prevent injury or inadvertent ligation.
Incise the peritoneum over the vascular pedicle and ligate the vessels close to their origins.
Divide the ileal mesentery between artery hemostats applied serially proximal and distal.
Protect the wound with abdominal packs and resect the bowel.
Options for restoring bowel continuity include a side-to-side or an end-to-side anastomosis
closure of the mesenteric defect, the abdominal cavity may be irrigated with sterile saline
With/without drain
Hemostasis is confirmed and omentum is positioned over the anastomosis , followed by closure.
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Left Hemicolectomy:
Principles:

The level of the Inferior mesenteric artery is

actually just inferior to the Duodenojejunal
junction.
The same is for the Inferior mesenteric vein
which is just lateral to the ligament of
Treitz.
The level of ligating the inferior mesenteric
artery will determined by the safe margin of
you resection. i.e if the mass is in the lower
descending the sigmoid must be resected to
include a safe margin and the Inferior
mesenteric artery will be ligated proximal
to the left colic branch, but if the lesion is in
the spleenic flexure: the sigmoid can be
preserved and the ligation will include the
left colic branch only.
Same principles in regard to the omentum as
right hemicolectomy, you include it only if the tumour is proximal.
As in the right colon, there is lateral to medial approach ( described below), and Mediolateral
approach.

Procedure: (Lateral to medial)

Loyid Davis (Modified Lithotomy) under GA.
Lower Midline incision.
Assess the liver, and peritoneum for any signs of mets.
Bookwalter or thombson retractor is very helpful to retract the bowel cephalic away.
Mobilize the left colon starting at the level of sigmoid until you reach the spleenic flexure
proximally and the rectosigmoid junction distally.
The ureter and the gonadal vessels should be identified at this stage crossing the iliac artery.
The left kidney and its Gerota’s fascia should be visible; then divide the colorenal attachment.
Free the omentum from the distal 10–12 cm of transverse colon
Now once the lesser sac is exposed, you can use the transverse colon as a guide and divide the
colopancreatic and colospleenic ligament, now the spleenic flexure should be free and fully
mobile.
Make an incision on the medial aspect of the mesocolon from the level of the duodenum down to
the promontory of the sacrum.
The inferior mesenteric artery is easily identified by palpation at its origin from the aorta
Now divide the inferior mesenteric vein as it passes behind the duodenojejunal junction and
pancreas, and divide either the left colic or the inferior mesenteric artery (see above).
Divide the mesocolon between clamps.
protect the wound and resect the colon.
Options for restoring bowel continuity include a side-to-side Colosigmoid anastomosis, end-to-
end Colorectal Anastomosis or stoma, and close the mesenteric defect.
The abdominal cavity may be irrigated with sterile saline
With/without drain
Hemostasis is confirmed and omentum is positioned over the anastomosis, followed by closure.
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Sigmoidectomy:
Principles:
If the tumour is in the sigmoid, you will resect the sigmoid with the upper part of rectum and the
procedure will be called sigmoidectomy. It can be called also Anterior resection (As long there is
no breach of the peritoneal fold, See later Low anterior resection)
The superior rectal artery is along the sigmoidal branches and it will be divided.
There is clear definition when the sigmoid ends and when the rectum starts, most agree around
12-15 cm from anal verge. (sarcal promenantry is an intraop landmark)
Same principles of mediolateral or lateral to medial approach.
You will have to mobilise the whole left colon including the spleenic flexure as in left hemi to
facilitate the anastomosis or the the stoma without tension.
Ligating the Inferior Mesentric artery at its base from the aorta is advised in high sigmoid mass
(more close to the left colon), and if the mass is more distal toward the rectum lower ligation
distal to the left colic is more appropriate.
The artery of Drummond is an accessory artery between the Superior Mesentric and the left colic,
and can supply the left colon after the ligation of the Inferior mesentric at its base, but it’s variable
between individuals. So if you divide the inferior mesenteric at its base assess the vascularity of
the left colon, and if needed you might have to extend the resection more proximally to a healthy
colon segment.
Procedure: (Lateral to medial)
The position is Loyoid Davis (Modified Lithotomy position).
Lower Midline incision.
Assess the liver, and peritoneum for any signs of mets.
Bookwalter or thombson retractor is very helpful to retract the bowel cephalic away.
Mobilize the left colon until the transverse colon, and the rectosigmoid junction.
The ureter and the gonadal vessels should be identified and preserved.
Ligate the Inferior Mesentric artery (as the principle above).
Divide the mesocolon between clamps.
Protect the wound and resect the colon.
Options for restoring bowel continuity include end-to-end Colorectal Anastomosis or stoma.
The abdominal cavity may be irrigated with sterile saline
With/without drain
Hemostasis is confirmed and omentum
is positioned over the anastomosis,
followed by closure.

Remember that the site to locate the

inferior mesenteric artery is just
inferior to the duodenum.

and the inferior mesenteric vein is just

lateral to the ligament of Treitz.
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Low Anterior Resection:

Principles:
Low = below the peritoneal fold of the rectum, Anterior= through abdominal approach.
Low anterior resections are performed to treat malignant tumors of the middle and upper thirds of
the rectum, 6–14 cm (and sometimes lower) from the anal verge.
Special Consideration in Rectal Cancer:
1. Physical, life expectance status and Sphincter function assessment preop
2. Endoanal Ultrasound staging for Accurate T staging and Pelvic MRI staging
3. Accurate assessment of Anal verge distance by rigid sigmoidoscopy
4. Performing proctoscopy is a must even when colonscopy is done, to assess the anal canal
which is missed in colonscopy.
5. Tattoing the distal margin of the tumour during colonscopy
6. Neodajuvant ChemoRadiotherapy, and the RESTAGING after it.
7. Sexual Dysfunction and Presacral bleeding as a possible complication.
8. The decision of Either Low anterior vs APR can be made pre operatively mainly based on
the distance of the tumor from the anal verge, but the final decision is to be made
intraoperativly. so in low rectal cancer consent for Low anterior vs APR.
9. Total Mesorectal Excision Principles.
10. The proximal margin is 5 cm while the distal margin can be as little as 2 cm.
11. The new modality of Endoanal Excision for T1 small lesions.
Same principles for Colon: Stoma marking, Tumour markers… See first page.

Procedure:
Modified Lithotomy under GA
Lower midline incision
Bookwalter retractor for full exposure and to retract the small bowel cephalic.
Assess the liver, and peritoneum for any signs of mets.
Full mobilization of the left colon, Sigmoid until the rectosigmoid junction, identifying the ureter
and gonadal vessels.
starting the medial dissection by incising the peritoneum at the intersigmoid fossa and extending
proximally to expose the Inferior mesenteric artery and distally to the right side of the rectum.
Ligate the Inferior mesenteric artery distal to left colic artery.
Protect the wound and using GIA 60 stapler transect the colon at the sigmoid colon junction and
use the sigmoid.
Use the transected sigmoid as guide by upward and superior traction to guide your dissection
towards the rectum and the pre sacral fascia
Incise the peritoneum surrounding the rectum form both sides until both incisions meet anteriorly.
the posterior dissection is started first, by SHARP dissection to include the mesorectum in total
with the rectum, which is identified by avascular loose areolar tissue (the holy plane). watch for
the hypogastric nerves plexus at the sacral promontory.
Retract the rectum anteriorly until you reach the pelvic floor.
retract the bladder anteriorly and Start the lateral dissection, midway along the dissection you will
encounter the lateral stalk containing the middle rectal vessels, ligate them. avoid lateral
dissection to protect the nervous plexus and the ureters. (Look at TME figure next page)
the anterior dissection is the most difficult due to lack of planes, divide Denonviller fascia and
avoid injuring the bladder, prostate or vaginal in females.
once the whole rectum is mobilized and dissected reassess the tumour and the distal margin.
if there is enough margin, transect and prepare for the anastomosis.
make sure there is no tension, good vascular healthy edges, using circular stable 28 or 30.
test the anastomosis by: checking the donut, air tight and by sigmoidoscopy to assess it from
inside.
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Anterior Perineal Resection:

Principles:
Anterior= Abdominal approach, Perineal= Perineal approach
The end red result will be permanent stoma
The perineal defect will be closed
same principles of low anterior resection.
Indication of APR :
Low rectal or anal cancer not amenable for spinster sparing procedure as in :
1. Patient already incontinant irrespective of the distance.
2. Inability to achieve a safe distal margin.

Procedure:
1- Abdominal Approach : is exactly as Low anterior resection.
2- Perineal resection:
The patient lies supine, with the sacrum elevated on a folded sheet or sandbag
The anus is already closed by a heavy, silk purse-string suture.
Elliptical incision in the skin beginning at a point 3–4 cm anterior to the anal orifice and
terminating at the tip of the coccyx down into the peri- rectal fat, down to the levator diaphragm
Divide The anococcygeal ligament at the tip of the coccyx.
two branches of the inferior hemorrhoidal vessels appear in the perirectal fat just superficial to the
levators.
Divide the dense condensation of fascia (Waldeyer’s fascia) attaches the posterior rectum to the
pre- sacral and precoccygeal area.
Because the greatest danger of the perineal dissection in men is the risk of traumatizing the
urethra, delay the anterior portion of the dissection until the end.
After all the anorectal complex is dissected and the dissection reaches the abdomen, the specimen
is covered with gauze and removed through the perineal defect.
The perineal defect is closed in layers, without any dead space and presacral drainage by inserting
one or two closed-suction drainage catheters,
abdominal surgeon has closed the pelvic peritoneum, and mature the permanent colostomy.

Potential Sites of nerve injury during Anterior resection:

Origins of inferior mesenteric artery at the aorta
Sacral Promonotry
Lateral ligament during lateral dissection
Behind the prostate and the seminal vesicle.

Survailance in Colorectal Cancer in postoperative period:

History and physical Examination with CEA level : Every 3 months for the first 2 years
History and physical Examination with CEA level : Every 6 months for another 3 years
Colonoscopy : 1st, 3rd and 5th year.
CT scan Abdomen for the first 3 years in high risk patients.

Criteria for Endoanal Excision:

1. Fully accessible from anus (usually 8-10 cm)
2. less than 3cm, less than 1/3 of the circumference of the rectum
3. mobile in rectal examination, no ulceration.
4. No distal Lymphondes
5. T1 by enodanal US , no lymphovascular invasion and well to moderate differentiation.
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Principles of Stoma site selection:

Avoid Scars, Skin Folds/Creases, Bony Prominence

Away Suture Lines
Away from Umbilicus, from Belt/Waistline and Radiation Sites
Should be easily seen by the patient

Principles of Anastomosis:
Patient Factors:
1. Advanced Malignancy
2. Malnutrition
3. Intraoperative blood loss, hypotension, hypoxia, or sepsis
4. Old age
5. Anaemia
Local Factors:
1. Peritoneal Sepsis: Gross contamination
2. Mechanical bowel preparation (controversial)
3. Drains
Technical
1. Access and Exposure : inadequate relaxation, poor assistance, inappropriate incision,
inadequate mobilization.
2. Blood supply: excessive use of diathermy.
3. Tension free

TME : Total Mesorectal Excision

Axial Section

Sagittal Section
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Inguinal Hernia Repair

Open hernia repair ; (common first steps in all hernia operation)

1. Incise the skin approximately 2–3 cm above and parallel to the inguinal ligament
2. Ligate the large veins (superficial epigastric, superficial circumflex, and external pudendal).
3. Open the aponeurosis of the external oblique muscle in the direction of its fibers.
4. Protect the ilioinguinal nerve.
5. Elevate the spermatic cord carefully and retract with a Penrose drain.
6. Identify the sac located anteromedial to the spermatic cord. Dissect it at the internal ring and
lateral to the deep epigastric vessels.
7. Ligate and amputate the sac.
the rest of the steps is different depending on what method you are following :
Classic Bassini: (3 to 2 repair)
8. Open Transversalis Fascia
9. Continues Suture of superior 3 layers (upper flap of Transversalis fascia + “Conjoint tendon” =
Internal Oblique + Transversus Abdominus) to the inferior 2 layers ( lower flap of Transversalis
fascia and inguinal ligament)

Modified Bassini: Conjoint Tendon repair (2 to 1 repair)

8. Transversalis fascia is NOT opened
9. 2 superior layers (“Conjoint tendon” =Internal Oblique + Transversus Abdominus) sutured to
inferior 1 layer which is the inguinal ligament .

Shouldice Repair: 4 layers repair

8. Open Transversalis Fascia
9. First layer: Lower flap free edge of Transversalis Fascia to the POSTERIOR aspect of the upper
flap of Transversalis Fascia
10. Second Layer: upper flap of Transversalis Fascia free edge to base of lower flap and Inguinal
ligament
11. Third Layer: Conjoint tendon to inguinal ligament
12. Fourth layer: Conjoint tendon to posterior aspect of the External Oblique Aponeurosis.
13. close the external oblique aponeurosis over the cord.

Mcvay: ( Obliteriate both inguinal and femoral defects)

8. Open Transversalis Fascia
9. Exposed and identify Coopers ligament (Iliopicteneal ligament)
10. Interrupted Sutures between the conjoint tendon to coopers ligament starting from the pubic
tubercle
11. until you reach the femoral vein then perform the (Transition stitch) which is conjoint to
coopers to inguinal ligament stitch
12. continue you the rest of the sutures between
conjoint and inguinal until the internal ring.
13. make a relaxing incision in the anterior rectus
sheath 2-3 cm above the tubercle extending
for about 10 cm superiorly, to decrease
tension in the repair ,,
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Only Mesh repair

Litchtenstein Repair:
8. A mesh prosthesis is positioned over the inguinal floor
9. The mesh should be at least 15 × 8 cm
10. the medial end is rounded to correspond to the patient’s particular anatomy and secured to the
anterior rectus sheath at least 2 cm medial to the pubic tubercle, then fix it with a superficial
stitch to the tubercle.
11. A continuous suture through the lower end of the mesh to the shelving edge of the inguinal
ligament. The suture is tied at the internal ring.
12. An incision is made at the lateral end of the mesh to create two tails, two thirds above and one
third below.
13. The tails are positioned around the cord structures and the upper tail placed on top of the lower
and sutured together to create new internal ring.
14. Then fix the mesh to the conjoint tendon, rectus
sheath

Plug and Patch inguinal Mesh repair: (Rutkow

repair)
Same as in Litchtenstein with the addition of a mesh
plug into the internal ring.

Ventral Hernia Repair principles:

Inlay, Sublay and Onlay Principles. See the figure

Laparoscopic Hernia repair

Indications:
bilateral inguinal hernias and recurrences from open approaches.
Contrindications:
Massive Scrotal hernia, Incarcirated non reducible, prior laparoscopic herniorraphy, prior major
pelvic operation or prior groin irradiation

1- Transabdominal approach (TAPP)

1. 3 ports first umbilical and two in the midclavicular line bilaterally. 
2. Reduce any hernial content.
3. 3-4 cm superior to the internal ring from the medial umbilical ligament to the anterior superior
iliac spine make an incision in the peritoneum and start dissection to create a peritoneal pocket.
4. dissect the hernial sac and reduce from the cord “if indirect”.
5. Care is taken to avoid the “Triangle of Doom” containing the external iliac vessels bordered by
the vas deferens medially and the gonadal vessels laterally.
6. Care to avoid to put any tackers in the “triangle of pain” Lateral to the gonadal vessels and
inferior to the iliopubic tract.
7. A mesh ranging from 10 to 15 cm is inserted in the created pre peritoneal space. 
8. The mesh can be fixed to coopers ligament and pubic tubercle, then peritoneum is closed.

2- Total extraperitoneal approach (TEP)

Its an extra peritoneal repair . advanced operation
not required from a general surgeon.
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Amputations

Below knee Amputation:

1. The anterior incision ideally 10 to 12 cm (three or four finger breadths) distal to the
tibial tuberosity.
2. The anterior incision extends from medial to lateral (3 o’clock to 9 o’clock)
encompassing one-half circumference of the leg.
3. Then elongate medially and laterally to create the posterior flap.
4. The length of the posterior flap is approximately one-third the circumference of the leg.
(some use a thread around the leg and divid it in 3 to estimate the length of the flap)
5. Incise The periosteum of the tibia circumferentially two finger breadths proximal to the
skin incision then cut the tibia, avoid sharp edges.
6. The fibula is divided with a saw 1 to 2 cm proximal to the tibial transection site
7. Achieve homeostasis by ligating anterior tibial, posterior tibial vessels
8. Then the flap is used to cover the tibia and the stump is closed

Above knee Amputation:

1. Transverse oriented fish-mouth incion with equal anterior and posterior flaps.
2. The fascia and muscles of the anterior thigh are divided.
3. The femur is transected two finger breadths proximal to the skin incision to provide
adequate skin and soft tissue coverage.
4. Achieve homeostasis by ligating the femoral vessels.
5. The deep fascia is approximated with absorbable suture. The skin can be closed using
staples
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Modified Radical Mastectomy:

Principles:
• The standard is lymph node dissection level 2
• Mark the tumour with permanent marker
• Plan the skin incision well, so it will close without tension
• Review the Histopathology, Radiology and the lab results
Preparation: 

Tumour Board, Full Staging, Consent, NPO, IVF, DVT prophylaxis, Antibiotics (controversial),
Marking peroperatively, Positioning with upper limb abduction, Blood group and save, all labs. 



Procedure: 

1- Supine position with ipsilateral arm 90 degree abducted under GA 

2- Draped from neck until costal margin 

3- Incision : elliptical transverse with 3 cm clearance around the tumour as outlined by marker, and
include any biopsy surgical scar. 

4- Incision from the lateral edge of the sternum to med axillary line (height below hairline) 

5- Dissection beyond the subcutaneous tissue is avoided 

6- Several clamp applied to the upper half with vertical traction and counter traction on the breast
tissue, within 5-8 mm thickness. 

7- Then start creating the upper flap to the level of the clavicle, then cover with moist lap pad. 

8- With the same technique the lower flap is created to the rectus sheath. 

9- The lateral edge will be the latissmus dorsi and the lateral edge of the sternum is the medial
border.

10- Start from the medial aspect by incising the pectoralis fascia from the lateral edge of the
sternum and sharply dissected from the pectoralis muscle, until the lateral edge of the pectorals
major muscle, and to include it with the breast specimen. 

11- Now we move to the axillary dissection: retract the pectorals major with two right angle
retractors.

12- Now the inter pectoral fat and lymph nodes are in field and should be dissected and retrieved
13- The medial pectoral nerve is identified and preserved 

14- To gain access to the axillary vein the clavipectoral fascia must be incised, and tributaries are
ligated, and dissection above the vein is avoided. 

15- Start dissection 5mm below the vein, then with retracting the pectorals muscle the dissection is
proceeded to realising the axillary tissue from the lateral chest wall, 

16- Serratous anterior facia should not be violated to protect the long thoracic nerve and search for
long thoracic nerve below it. 

17- Then identify the thoracodorsal pedicle by identifying the lateral thoracic vein which is most
anterior tributary to the axillary vein 

18- The axillary tissue between the two nerve is grasped and removed, with preservation go the
intercostobrachial nerve if possible. 

19- Dissection is continued caudally to remove the rest of the axillary content . 

20- Insert two drains, one in axilla and one under the flaps.
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Open Thyroidectomy
Preoperative Preparation:
Tumour Board, Full Staging, Consent, NPO, IVF, DVT prophylaxis, Antibiotics (controversial),
Reviewing the ultrasound report, Positioning with neck extension (Controversial), Blood group and
save, all labs, specifically Bone profile and TFTs, Vocal cord Preop assessment. 


Procedure:
1. Skin incision: A curvilinear incision is placed in a skin crease two fingerbreadths above the
sternal notch between the medial borders of the sternocleidomastoid muscles, The width of the
incision may need to be extended for large goitres.
2. Dividing the platysma and Creating the Subplatysmal flaps: Subplatysmal dissection plane is
developed superiorly (platysma is often absent in the midline) remaining superficial to the
anterior jugular veins, up to the level of the thyroid cartilage above, and the sternal notch below.
3. The skin flaps are secured to Jowell’s retractor.
4. Separating strap muscles and exposing the anterior surface of thyroid: The fascia between the
sternohyoid and sternothyroid muscles is divided along the midline with diathermy or scissors.
5. Medially rotating the thyroid: Using gentle digital retraction the surgeon rotates the thyroid
gland medially
6. Dividing the middle thyroid vein.
7. Dividing the Superior Thyroid Artery: The retractors are repositioned to allow full visualisation
of the superior pole of the thyroid and divide the artery as close to the thyroid parenchyma as
possible to avoid injury to the external branch of the superior laryngeal nerve.
8. Identifying superior parathyroid gland, and preserve it (How? common question). The superior
parathyroid gland is normally located at the level of the upper two-thirds of the thyroid, in a
posterior position.
9. The retractors are again repositioned to expose the lower neck and the inferior thyroid vessels.
The vessels are divided, and ligated.
10. Identifying inferior parathyroid gland; (How? common question) The inferior parathyroid
glands are normally located between the lower pole of the thyroid and the isthmus, most
commonly on the anterior or the posterolateral surface of the lower pole of the thyroid.
11. Dividing Ligament of Berry: The posteromedial aspect of the thyroid gland is attached to the
side of the cricoid cartilage and to the 1st and 2nd tracheal rings by the posterior suspensory
ligament/ Ligament of Berry. Identifying The RLN: (How? common question) the nerve is in
close proximity (<3mm) to the ligament and usually passes posterior to the ligament and must
be identified before the ligament is divided. avoid any cautery in this area.
12. The wound is irrigated and haemostasis is achieved.
13. Wound drainage is not routinely required; if necessary a suction drain is positioned in the
thyroid bed and brought out through a laterally placed skin puncture.
14. The strap muscles are approximated for 70% of their length, and the platysma is closed with
interrupted absorbable 3/0 sutures.
15. skin closure is achieved and light dressing is applied.
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Open cholecystectomy
Preoperative: 

NGT, IVF, Folly’s, Antibiotics, DVT prophylaxis, Instruments and fluroscopy compatible table (T-
tube, Cholangiogram dye (1:1 dilution), C-arm, endoscopic Basket, fogarty catheter, Pediatric NG
tube, Choldecoscope, Stone forceps, Bile bag.

Preparation: 

Consent, NPO, IVF, DVT prophylaxis, Antibiotics, Blood group and save, all labs

Procedure
1. Incision Kochers or midline.
2. Kocher's 2 finger-breadth below subcostal margin , anterior rectal sheath is incised, and
rectus is divided by cautery and ligation of epigastric vessels and hemostasis, posterior
rectus sheath incised, then the peritoneum is open after grasped by two haemostats.
3. Exploration to exclude any other pathology.
4. Exposure of the gallbladder by the following steps:
A. Elevate the head of the bed to 15
B. Operator hand is inserted between the liver and the diaphragm to by break the suction and
bring the liver down to the field.
C. Using 4 laparotomy pads :
- pack the hepatic flexure down
- pack off the lesser curvature of the stomach to the left
- place wet laparotomy pad under a Harrington’s or Deaver retractor to retract the liver
- use addition pad to pack off the small intestine and the duodenum.
5. Any adhesions between the gallbladder and adjacent structures is divided
6. The cystic duct and gallbladder are gently palpated to feel for any stones
7. Identify Hartman’s pouch and grasp by an ovum clamp and retract it laterally to place cystic 

duct on tension
8. And additional clamp to the fundus to provide further traction.
9. The assistant retract the duodenum downward to place the CBD on tension.
10. If there is evidence of sever fibrosis or adhesion its wise to start the dissection from the
funds, otherwise the standard is to start the dissection in the Calot’s triangle
11. The dissection should be started close to the gallbladder wall to avoid injuring bile ducts.
12. The peritoneum over the Calot’s triangle is incised gently and dissected toward the liver and 

bluntly dissected off the duct in two opposing directions using peanuts
13. By using blunt dissection the cystic duct is identified and the junction with CBD is identified
14. The cystic duct is traced toward the gallbladder
15. The cystic artery is dissected free with a right angle clamp and doubly ligated and divided.
16. A loose knot is tied around the cystic duct and dissection is started by a retrograde fashion
by retracting the fundus laterally to open up the plane of dissection between the gallbladder
and its bed, by blunt and sharp dissection ,,
17. Once the gallbladder is freed from its bed, and confirming that the cystic is is the true cystic 

duct the knot is tied completely and divided ,,
18. The gallbladder is removed , hemostasis secured and drain inserted.
19. Closure is done in either in two layers fashion or one layer. 

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