1. Chapter 23
General Surgery

2. General Surgery Important terms and definitions
Review terms and definitions listed at beginning of chapter
Use your medical dictionary if necessary
Familiarize yourself with terminology found in the beginning of the chapter.
General surgery is performed by a general surgeon.
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3. General Surgery Abdominal surgery Abdominal wall Gastrointestinal
Biliary – Gall bladder
Spleen
Pancreas
Hepatic
Breast (noncosmetic)
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4. General Surgery Four quadrants of the abdomen.
What are the four quadrants of the ventral abdomen?
What are the nine regions identified by an imaginary grid that divides the ventral abdomen?
(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Churchill Livingstone, Edinburgh, 2007, Elsevier.)
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5. General Surgery
Tissue layers of the abdominal wall and muscles of the abdomen.
The tissue layers of the abdominal wall include
Skin
Subcutaneous
Muscles
Deep fascia
Subserous fascia
Abdominal peritoneum
Epigastric
Hypogastric
The layers are often sutured separately.
Suture materials for each layer are strong enough to approximate (bring together) the layer after it has been surgically cut, but fine enough to cause as little trauma as possible. These are technical points that contribute to wound management and a successful surgical outcome.
(From Drake R, Vogel W, and Mitchell A: Gray’s Anatomy for Students, Edinburgh, 2004, Churchill Livingstone.)
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6. General Surgery Abdominal incisions Midline Paramedian Subcostal Flank
Inguinal
McBurney's
Incisions for general surgery procedures are made depending on the area requiring surgery and the desired cosmetic result.
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7. General Surgery Abdominal incisions.
An incision made just right or left of the midline will involve the rectus abdominus muscle.
For what types of surgery would an upper paramedian incision be made?
(Modified from Rothrock JC: Alexander’s care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)
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8. General Surgery Inguinal region Hesselbach’s triangle Inguinal canal
Spermatic fascia
Cremaster muscle
Genitofemoral nerve
Ductus deferens
Lymph vessels
Testicular vein and artery
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9. General Surgery Types of hernias Inguinal (direct or indirect hernia)
Femoral hernia
Incisional or ventral hernia
Umbilical hernia
Spigelian hernia
What is a hernia?
What are the different types of hernias?
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10. General Surgery Common inguinal hernias Strangulated Obstructed
Why do males have a higher incidence of inguinal hernias than females?
The spermatic cord is often involved in the inguinal hernia.
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11. General Surgery Open Repair of Indirect Inguinal Hernia
Incising aponeurosis of external oblique muscle.
Blunt dissection of the hernia sac from the spermatic cord.
Open hernia repair is performed to restore strength to the inguinal floor and prevent abdominal tissue from extruding into the inguinal canal.
What is a strangulated hernia?
(Colorized from Moody FG: Atlas of ambulatory surgery, St Louis, 1999, Mosby.)
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12. Placing the purse-string suture at the neck of the hernia sac.
General Surgery
Open Repair of Indirect Inguinal Hernia
Placing the purse-string suture at the neck of the hernia sac.
Opening the hernia sac.
A moist Penrose drain will be used as a retractor for the spermatic cord and the vas deferens.
For large sacs, a purse string of 2-0 synthetic absorbable suture is placed around the neck of the sac, which is then removed and sent as a specimen.
(Colorized from Moody FG: Atlas of ambulatory surgery, St Louis, 1999, Mosby.)
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13. Suturing the mesh graft.
General Surgery
Open Inguinal Hernia with Patch Graft
Suturing the mesh graft.
(Colorized from Moody FG: Atlas of ambulatory surgery, St Louis, 1999, Mosby.)
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14. General Surgery
Transabdominal Extraperitoneal (TEP) Inguinal Hernia Repair.
No pneumoperitoneum is used for TEP hernia repair.
A possible complication of TEP would result if the trocars were accidentally placed in the peritoneal cavity.
A balloon expander inserted into the incision and inflated with air or normal saline.
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15. General Surgery Femoral hernia Surgical goal
An open repair of a femoral hernia is performed to restore strength to the inguinal floor and prevent abdominal tissue from protruding into the inguinal canal
Why do femoral hernias occur most often in females?
The femoral hernia sac will be sent as a specimen.
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16. General Surgery Incisional or ventral hernia
To remodel a previous abdominal wall scar and provide sufficient strength to prevent a recurring hernia
What can cause weakness in tissues from a previous incision site?
Nonabsorbable sutures from previous surgery will need to be removed.
The surgeon may attempt to reestablish normal tissue planes.
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17. General Surgery Umbilical hernia repair
Completed to repair weakening of abdominal wall around or under umbilicus
Why are obese patients at risk for umbilical hernias?
The surgical technologist may be asked to hold a retractor as well as pass instruments during a hernia repair.
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18. General Surgery Spigelian hernia repair
Completed to reduce protrusion of abdominal viscera in “Spigelian zone”
Spigelian hernias are uncommon and hard to diagnose. A Spigelian hernia is located between the different abdominal layers. It may also be called an interparietal, interstitial, or intramuscular hernia.
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19. General Surgery Introduction to gastrointestinal surgery Anatomy
Esophagus
Stomach
Small intestine
Large intestine (colon)
Rectum and anus
What is an anastomosis?
What is a resection?
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20. General Surgery Anatomy of the stomach.
What are the three major sections of the stomach?
Whenever a portion of the stomach is removed or remodeled, the omentum must be divided from its attachments.
(Colorized from Rothrock JC: Alexander's care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)
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21. General Surgery Anatomy of the small intestine.
What is the function of the small intestine?
What are the sections of the small intestine?
(Colorized from Rothrock JC: Alexander's care of the patient in surgery, ed 12, St Louis, 2003, Mosby.)
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22. General Surgery Anatomy of the large intestine.
The large intestine extends from the distal end of the small intestine, the ileum, to the rectum and is divided into five distinct sections. These sections are the ascending colon, the transverse colon, the descending colon, the sigmoid colon, and the rectum.
The entire large intestine measures about 1.5 meters (5 feet) in the adult.
(Modified from Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.)
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23. General Surgery Rectum and anus.
The rectum is continuous with the anal canal and the anus. The rectum is approximately 10.2 to 12.7 cm (4 to 5 inches) long.
The anal canal extends from the rectum to the outside of the body. Near the anus, the muscular fibers form both internal and external sphincters that control the release of feces to the outside of the body.
These sphincters contain large veins that, if they become engorged and enlarged, are called hemorrhoids. A complex of muscles, connective tissue, glands, and mucosa form the anus.
(Modified from Applegate EJ: The anatomy and physiology learning system, ed 2, Philadelphia, 2000, Saunders.)
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24. General Surgery Bowel technique
Separate area on Mayo or basin for instruments used while the bowel is open
Upon closure of the bowel, contaminated instruments are removed from the field
Before abdominal closure, gown (per facility policy) and gloves are changed
Instruments that come in contact with the bowel are contaminated and should be placed on a separate Mayo stand or in a separate basin.
Why does the surgical team regown and reglove after the bowel is closed?
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25. General Surgery Special procedures Esophagogastroscopy Duodenoscopy
Colonoscopy
Sigmoidoscopy
Patients undergoing endoscopic procedures are usually given intravenous (IV) sedation.
What does a bowel prep for an endoscopic procedure include?
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26. General Surgery Esophagogastroscopy Duodenoscopy
Endoscopic inspection of esophagus and stomach
Duodenoscopy
Endoscopic inspection of duodenum
Patients undergoing an endoscopy through the oral route must be warned of a delayed return of their gag reflex owing to topical anesthetic that is sprayed in the throat before the procedure.
What is assessed during an esophagogastroscopy?
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27. General Surgery Colonoscopy Sigmoidoscopy
Endoscopic inspection of colon
Sigmoidoscopy
Performed to examine tissue or obtain biopsy specimen
What position is a patient placed in for a sigmoidoscopy or colonoscopy?
Sigmoidoscopes do not have a built-in suction and irrigation system. The surgical technologist will have to hold the suction tip for the doctor.
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28. General Surgery Laparotomy Open surgery of the abdominal cavity
Confirm a diagnosis
Exploratory
Why is an exploratory laparotomy performed?
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29. General Surgery Excision of esophageal diverticulum
Removal of a portion of the esophagus, followed by a straightening to prevent recurrence
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30. General Surgery Laparoscopic Nissen fundoplication
Commonly performed to treat gastroesophageal reflux disease (GERD)
Reference Figure 23-15, A in the textbook for trocar placement sites used in Nissen fundoplication.
What is GERD?
What secondary health concerns can result from untreated GERD?
View of gastroesophageal (GE) junction with a portion of the stomach protruding through the hiatus.
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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31. General Surgery Laparoscopic Nissen Fundoplication (cont.)
Sutures are placed through the crura to close the defect.
Dissection of the crura to expose
the hiatus.
The patient is placed in a low lithotomy position.
The liver is retracted with either a liver retractor or atraumatic forceps.
The surgical technologist must have plenty of suture ready for suturing the hiatus.
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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32. General Surgery Laparoscopic Nissen Fundoplication (cont.)
A gastric tube or bougie is passed through the esophagus and into the stomach to gauge the tightness of the gastric sleeve.
What would be the consequences for the patient if the sleeve was too tight? Too loose?
Fundoplication or wrap of stomach around distal esophagus. An esophageal catheter (bougie) has been inserted.
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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33. General Surgery Vagotomy Performed to decrease gastric juices
Procedure involves selective occlusion of vagus nerve
Traditionally used to treat peptic ulcer
Current knowledge has reduced number of operations
Vagotomy is the resection of the vagus nerve.
What is used to ligate the vagus nerve?
How many vagus nerve branches are ligated or resected?
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34. General Surgery Percutaneous endoscopic gastrostomy (PEG)
Common method of providing nutrition via a flexible tube inserted through the abdominal wall
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35. General Surgery Partial gastrectomy Billroth I & II.
Why is a thoracoabdominal (TA) stapling device used to resect the stomach?
What other stapling devices are used besides the TA 55 in the Billroth II procedure?
(From Economou SG, Economou TS: Atlas of surgical technique, ed 2, Philadelphia, 1996, Saunders.)
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36. General Surgery Gastroduodenal anastomosis.
Intestinal anastomosis techniques are based on the preferences and training of the surgeon.
A wound drain may be placed to prevent a postoperative infection.
(From Economou SG, Economou TS: Atlas of surgical technique, ed 2, Philadelphia, 1996, Saunders.)
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37. General Surgery Laparoscopic adjustable banded gastroplasty
Reduces nutrient absorption to deal with morbid obesity
Two effective procedures are
Vertical gastric banding
Roux–en–Y gastric bypass
Banded gastroplasty is done for morbid obesity. What is morbid obesity?
What secondary health problems are associated with morbid obesity?
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38. General Surgery Banded Gastroplasty
A bougie is a weighted, flexible rubber dilator.
What laparoscopic instruments will be used to mobilize the stomach?
The visceral peritoneum is divided at the antrum of the stomach (angle of His).
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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39. General Surgery Banded Gastroplasty
Tunneling instrument is placed behind the stomach.
Inflatable band is inserted through the tunnel.
The surgeon will create a 5-mm stomach pouch.
What stapling device is used to place a double row of staples across the fundus without cutting through it?
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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40. General Surgery Banded Gastroplasty Band is locked in place.
Why is the gastric band made of polypropylene?
Methylene blue will be inserted into the stomach pouch to test the staple lines.
Band is locked in place.
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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41. General Surgery Roux-en-Y Gastric Bypass
What health conditions has a Roux-en-Y procedure traditionally been used to treat?
What stapling devices will be used to perform a Roux-en-Y procedure?
A, Division of the jejunum with surgical stapler B, Placing the stapler to perform side to side anastomosis. C, Creation of the gastric pouch.
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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42. General Surgery Transhiatal esophagectomy
Performed for adenocarcinoma and squamous cell carcinoma
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43. General Surgery Transhiatal esophagectomy
Performed through combined cervical and upper midline incisions
The esophagus is mobilized to the hiatus through the cervical incision, and the stomach is mobilized through the abdominal incision.
The stomach is brought upward, and an anastomosis is formed with the proximal esophagus.
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44. General Surgery Segmental resection of the small intestine
Removal of a section of the small intestine with an anastomosis to maintain continuity of the intestinal tract
Anastomosis
End-to-end
Side-to-end
Side-to-side
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45. The clamped intestinal stumps are aligned.
General Surgery
End-to-End Anastomosis
The clamped intestinal stumps are aligned.
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46. General Surgery End-to-End Anastomosis The mucosa is sutured.
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47. The muscle and serosa layers are sutured.
General Surgery
End-to-End Anastomosis
The muscle and serosa layers are sutured.
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48. General Surgery Removal of Meckel’s diverticula
Surgical removal of the distal ileum
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49. General Surgery Resection of the colon
Removal of a section of the large intestine and its continuity restored by anastomosis, or development of a colostomy (stoma)
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50. General Surgery Colostomy
A, A disk of tissue is removed from the body wall. B, The intestinal stump is brought through the opening in the skin. C, The bowel may be sutured on the internal side. D, The bowel is everted and sutured to the skin. E, Healed stoma.
A-D Colorized from Bauer JJ: Colorectal surgery illustrated, St. Louis, 1993 Mosby. E from Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Churchill Livingstone, Edinburgh, 2007, Elsevier.
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51. General Surgery Partial colectomy
Performed to remove a section of diseased colon and restore continuity to the intestine
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52. General Surgery Ileotransverse colostomy
Surgical removal of a portion of the ileum and transverse colon and a side-to-side anastomosis of the ileum and colon
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53. General Surgery Right hemicolectomy
Removal of diseased portion of right colon
Bowel continuity reestablished by anastomosis
After the diseased colon is removed, the surgeon may use a circular end-to-end anastomosis (EEA) stapler to perform the ileostomy.
The surgical technologist must pay close attention to the EEA anvil. It is a small piece that can be easily lost.
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54. General Surgery Abdominoperineal resection of the rectum (APR)
Performed to treat cancer of the rectum
Necessitates formation of permanent colostomy in abdominal wall
An abdominoperineal resection is performed as two simultaneous yet separate procedures. One team is working from the abdomen while the other is working below from the rectum.
The patient is in the low lithotomy position, allowing both teams to work at the same time.
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55. General Surgery Abdominoperineal resection.
When one team is performing the low anterior resection, a complete change of instruments, drapes, gowns, and gloves is necessary between the upper and lower phases.
The abdominal phase is completed first.
B, The transverse anastomosis (TIA) stapler is used to close the rectal stump following resection of the abdominal colon. C, The gastrointestinal anastomosis (GIA) is used form an anal pouch using the ileum. The end-to-end anastomosis (EEA) is used to bring the stapled ileal pouch into position. It can then be hand sutured in place.
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
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56. General Surgery Appendectomy Removed when acutely infected
Sometimes removed as prophylactic procedure (incidental appendectomy)
Can be done as open procedure or laparoscopic procedure
Incidental appendectomies may be performed with bowel resections and abdominal hysterectomies.
What type of incision is made for an appendectomy?
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57. General Surgery Open appendectomy Used when perforation has occurred
A, The appendix is divided from the cecum after ligation. B, A purse-string suture is placed around the stump. C, The stump is buried, and the purse string suture closed.
(From Ortega JM Ricardo AE: Surgery of the appendix and colon. In Moody FG: Atlas of ambulatory surgery, Philadelphia, 1999, WB Saunders.)
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58. General Surgery Laparoscopic appendectomy
More common than open appendectomy
In endoscopic appendectomy, a pneumoperitoneum must be established.
Recovery time is faster for a laparoscopic appendectomy than an open appendectomy.
A laparoscopic appendectomy site leaves little scarring, because small trocars are used.
D, Laparoscopic appendectomy: The appendix is amputated using the GIA stapler. E, The mesoappendix is divided. F, The appendix is brought out of the abdomen through one of the operative ports.
(From Moody FG: Atlas of ambulatory surgery, Philadelphia, 1999, WB Saunders.)
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59. General Surgery Hemorrhoidectomy Hemorrhoids are classified as
Internal (inside the rectum)
External (outside the rectum)
What are the signs and symptoms of a hemorrhoid?
Make sure the patient’s breasts, knees, elbows, scrotum, and feet are well padded to prevent a pressure injury.
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60. General Surgery Excision of pilonidal cyst
Epithelial tissue trapped below skin’s surface in area of sacrum and coccyx
Cyst is removed when it causes recurrent infection
Sinus tract often present
In what position is a patient placed for an excision of a pilonidal cyst?
The surgeon may inject dye into the sinus tract. If so, the scrub must have a blunt needle, syringe, and methylene blue available.
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61. General Surgery Excision of Anal Fistula
What is a probe?
What is a groove director?
What are the signs and symptoms of an anal fistula?
Anal fistula involving the sphincter.
(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5, Edinburgh, 2007, Churchill Livingstone Elsevier.)
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62. General Surgery
Surgery of the biliary system, the liver, the pancreas, and the spleen
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63. General Surgery
Locations of the liver, the gallbladder, and the pancreas.
The liver, the gallbladder, the spleen, and the pancreas are situated in the midabdominal cavity.
(Modified from Herlihy B, Maebius NK: The human body in health and illness, ed 2, Philadelphia, 2003, Saunders.)
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64. General Surgery Biliary system.
The biliary system includes the gallbladder, the hepatic ducts, the cystic duct, and the common bile duct.
The gallbladder is a small sac located underneath (ventral side) the right lobe of the liver. It is composed of smooth muscle and has an inner surface of absorptive cells.
The function of the biliary system is to produce, store, and release bile. This substance is necessary for the breakdown of cholesterol and to help stimulate peristalsis in the small intestine during digestion. Bile is formed in the liver and stored in the gallbladder.
It is composed of bile salts, pigments, cholesterol, lecithin, mucin (a glycoprotein), and other organic substances.
(From Drake R, Vogl W, Mitchell A: Gray’s Anatomy for Students, Edinburgh, 2004, Churchill Livingstone).
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65. General Surgery
Anatomical relationship of the spleen and the arterial system.
The spleen is a kidney-shaped organ that is extremely vascular and relatively soft. It lies under the diaphragm in the left upper abdomen.
This organ destroys aged red blood cells, stores blood, filters microorganisms from the blood, and plays a major role in the immune system of the body.
The spleen is supplied by two major blood vessels: the splenic vein and artery. Because of its vascularity and location, the spleen is subject to trauma by direct blow during vehicular and other accidents.
The spleen can be safely removed without harm to body function; this procedure is indicated whenever splenic hemorrhage becomes life threatening.
(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5 Edinburgh, 2007, Churchill Livingstone Elsevier.)
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66. General Surgery Endoscopic retrograde cholangiopancreatography (ERCP)
Select patients may benefit from this procedure before biliary, hepatic, and pancreatic surgeries
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67. General Surgery Laparoscopic cholecystectomy
Complete surgical removal of gallbladder
Performed to prevent or treat inflammation or obstruction
Common diseases of biliary system
Cholelithiasis – Presence of gallstones
Cholecystitis – Inflammation of bladder
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68. General Surgery Cholecystectomy (open)
A cholecystectomy is the removal of a diseased gallbladder
In acute cholecystitis, the normally bluish-green gallbladder becomes distended and inflamed owing to obstruction by one or more gallstones. In removing the gallbladder, the common bile duct is left unimpaired so that it becomes a functional passageway through which bile can enter the duodenum.
Technique:
The abdomen is entered.
The bile ducts are identified and isolated.
The cystic artery is identified and ligated.
The cystic duct is ligated.
The gallbladder is dissected from the liver bed.
The wound is closed.
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69. General Surgery Operative cholangiography
Comprises imaging studies in which a contrast medium is injected into the biliary ducts to detect gallstones or a stricture
Regardless of the type of cholecystectomy performed (open or laparoscopic), cholangiograms will be performed to check for the presence of stones in the common duct.
Once a stone or group of stones is located on the radiograph, the stones are removed and the ducts are dilated.
Once the surgeon has identified the common duct, two traction sutures of 3-0 silk are placed through the wall of the duct.
An incision is then made between the sutures with a No. 15 or No. 11 scalpel blade or Potts scissors.
The scrub should have a catheter for insertion into the duct, radiopaque dye, and a 30- or 50-mL syringe available.
All air bubbles must be removed from both the syringe and the catheter. To do this, the scrub holds the syringe upright and injects a tiny amount of dye solution through the catheter. Tapping the syringe gently should cause the bubbles to rise to the top of the syringe, where they can be ejected out of the catheter.
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70. General Surgery Splenectomy
Removal of the spleen to stop hemorrhage caused by trauma or to treat disease
When is a splenectomy an elective procedure?
Hemorrhage is always a concern when performing a splenectomy.
There are four steps to correct acute hemorrhage:
Access—the surgeon must have access to hemorrhage site.
Visualization—the surgeon must be able to directly see the structures. The surgical technologist will need to suction immediately upon entry into the abdomen.
Good lighting—angle the surgical light toward the head of the wound.
Clamps—long occluding clamps must be available and ready for use.
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71. General Surgery Pancreaticojejunostomy (Whipple procedure)
A Whipple procedure is performed to treat pancreatic cancer
Include vascular instruments with your setup in case vessel repair is needed.
The cell-saver may be used because extreme blood loss is anticipated in a Whipple procedure.
(From Garden O, Bradbury A, Forsythe J, Parks R: Principles and practice of surgery, ed 5 Edinburgh, 2007, Churchill Livingstone Elsevier.)
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72. General Surgery Endoscopic distal pancreatectomy
Removal of portion of pancreas
For palliative treatment of malignant tumor
To remove benign lesion
The 5-year survival rate of pancreatic cancer is less than 3%.
Four abdominal ports are created.
The pancreas is divided by a GIA stapler. An endopouch is used to collect the resected specimen.
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73. General Surgery Surgical resection of the liver Wedge resection
Segmental resection
Lobectomy
The type of resection used depends on the type of tumor, the nutritional status of the patient, and the function of the liver at the time of surgery.
The most common indication for liver resection is a malignant tumor.
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74. General Surgery Segmental section
Goal is removal of one or more defined liver segments
A large self-retaining retractor is often used in segmental liver resections.
The surgical technologist must be aware that sponges are often retained in the subphrenic area. This area must be checked frequently for retained sponges.
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75. General Surgery Liver transplantation
One of most successful transplant procedures
Potential recipients screened
Is disease life threatening or reversible?
Is disease correctable by transplant?
Age of recipient?
Previous abdominal surgery?
Psychological and psychosocial considerations?
Physical status?
Organs are procured through what means?
Liver transplantation is one of the most successful transplant procedures performed.
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76. General Surgery Breast surgery
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77. General Surgery The breasts
Are functional part of female reproductive system
Provide milk for the infant
Respond to hormonal changes
Can have effect on sexual identification and body image
The breasts are typically located between the third and the seventh ribs.
Breast tissue changes with hormonal changes, pregnancy, and nutritional state of the patient.
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

78. General Surgery Anatomy of the breast. What is the areola?
What are Montgomery’s tubercles?
(From Donegan WL, Spratt JS: Cancer of the breast, Philadelphia, 1988, WB Saunders.)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

79. General Surgery Psychological considerations Instruments and supplies
Surgery can produce anxiety and depression
Respect and presence are critical components of patient care
Instruments and supplies
Unlike most other procedures, there are psychological considerations to breast surgery that the operating room (OR) team may have to address with the patient immediately pre-op. The breasts reflect reproductive ability and sexuality for many women.
Reconstructive surgery may take place immediately following the breast procedure or at a later date.
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

80. General Surgery Wire localization and breast biopsy
A fine wire is inserted into the breast during fluoroscopy
This is a specific technique used to identify the site of a suspected mass
Needle localization biopsy is the insertion of a fine needle into a nonpalpable abnormal breast mass observed during mammography.
The purpose of the needle insertion is to identify the exact location of the mass for subsequent biopsy and microscopic examination. A definitive diagnosis can then be made.
The procedure is done under x-ray guidance and is done preoperatively. The patient is then taken to the OR for an open breast biopsy.
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

81. General Surgery
Breast-conserving surgery for a mass (lumpectomy, segmental mastectomy)
A breast mass is removed to confirm a diagnosis or to treat malignancy
The goal of breast-conserving procedures is to minimize the amount of tissue taken while removing the malignant tumor and a wide marginal area.
What are the indications for a lumpectomy?
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

82. Incisions for a skin-sparing biopsy.
General Surgery
Breast-Conserving Surgery for a Mass (cont.)
Incisions for a skin-sparing biopsy.
Describe the prep for a subcutaneous mastectomy.
Ray-Tec sponges can be lost easily in a breast incision. Laparotomy sponges should be used for larger breast incisions.
(From Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

83. General Surgery Axillary dissection
Axillary lymph nodes can include cancer cells from a malignant tumor
Level II lymph node dissections are performed with breast-conserving surgery.
What types of drains may be placed in the axilla before closing?
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

84. General Surgery Total mastectomy with axillary lymph node dissection
Goal is to remove breast and axillary lymph nodes
In skin-sparing mastectomy, overlying skin tissue, areola, and nipple are not removed
If the lymph nodes are involved, level III node dissection is performed.
A mastectomy is usually followed by radiation therapy.
Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.