INTRODUCTION
TO SURGICAL
PROCEDURES
The primary goal of surgical
intervention is to return the patient
to their best possible state of
physical and mental health
1
SURGICAL INTERVENTION
TERMS
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Restorative – surgery performed to restore patient’s health;
return function to diseased or injured organs
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Prophylactic – surgery performed to prevent disease or
condition
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Palliative – surgery to treat symptoms without curing
underlying cause
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Diagnostic – surgery performed to diagnose a disease or
condition
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INDICATIONS FOR SURGERY
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DX Procedures
Trauma
Metabolic disease
Infection
Repair of congenital defect
Treat a neoplasm
Relieve an obstruction
Reconstruction
Aesthetics
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TERMONOLOGY
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-centesis
-desis
-ectomy
-lithotomy
-oscopy
-ostomy
-otomy
-pexy
-plasty
-rrhaphy
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General Dimensions – ABD & Pelvic
Cavities
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From diaphragm to base of the
pelvis
Bounded by bony structures:
ribs superiorly,
superoanteriorly,
superoposteriorly;
iliac crests inferiolaterally;
pelvic girdle inferiorly
and
inferoposteriorly;
vertebrae posteriorly
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Boney landmarks
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xiphoid process
subcostal margin
anterior iliac crests
symphysis pubis
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Abdomen Proper
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Contains the
majority of the: GI
tract, liver,
gallbladder,
pancreas, spleen,
kidneys, suprarenal
glands, blood and
lymph vessels,
nerves
7
Lesser Pelvis
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Contains coils of the digestive tract and its
most distal portions
Blood and lymph vessels
Lymph nodes
Nerves
Reproductive and urological organs
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Surface Features
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Umbilicus
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Linea alba
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Median groove created by the joining of the abdominal
aponeuroses
Semilunar lines of Spieghel
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Level of the disk between the 3rd and 4th lumbar vertebrae
Lateral margins of the rectus abdominis muscles
Bilateral abdominocrural creases
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Between the thigh and the abdomen
9
Abdominal Musculature
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External and external
oblique
Transverse abdominis
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“flat” muscles attach at
varying levels to the lower
ribs and the iliac crests
Rectus abdominis
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Long straplike muscle,
arises from the costal
margin and sides of the
xiphoid process and
extends to the symphysis
pubis
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Peritoneum
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A continuous thin serous membrane that:
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Lines the abdominal cavity – parietal
Covers the abdominal organs – visceral
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Semi-permeable – allows for passive
diffusion
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Retro-peritoneum
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Posterior to the abdominal parietal
peritoneum
More of a plane than a space
Extends from the diaphragm to the pelvis
Bounded by the abdominal parietal
peritoneum anteriorly, the spine posteriorly;
superiorly by the 12th ribs, inferiorly by the
pelvis
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ALIMENTARY CANAL
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Esophagus
Cardiac sphincter
Stomach
Pyloric sphincter
Duodenum
Jejunum
Ileum
Ileocecal valve
Cecum
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Ascending colon
Hepatic flexure
Transverse colon
Splenic flexure
Descending colon
Sigmoid colon
Rectum
Anus
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Esophagus
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24 cm long
Passes through the mediastinum
Connects the pharynx with the stomach
Divided into upper, middle, and lower
Closed at each end by sphincter muscle:
upper- pharyngoesophageal; lower esophagogastric
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Esophagus cont.
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Blood supply: upper – inferior thyroid
artery; middle – bronchial and intercostal
arteries; lower – celiac artery
Venous drainage: right and left gastrics
Lymph drainage: internal jugular, tracheal,
intercostal, diaphramatic and gastric nodes
Innervation: vagus nerve (X), cervical and
thoracic ganglia
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Stomach
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Lies in the epigastric,
umbilical, and left
hypochondriac regions
Consists of the cardia,
fundus, corpus,
antrum, and pylorus
Lesser curvature
(superior), greater
curvature (inferior)
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Stomach
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Musculature: 3 layers
– longitudinal layer,
circular layer, oblique
layer
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Internal folds - rugae
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Stomach
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Blood supply: left
gastric artery, splenic
artery
Venous drainage: left
gastric vein, right
gastric vein
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Stomach
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Innervation: left
(anterior) and right
(posterior) vagal nerve
trunks, thoracic roots
7-9
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Small Intestine
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Begins at the pyloric sphincter
Three segments: proximal – Duodenum,
middle – jejunum, distally – ileum
Jejunum and ileum are the mesenteric
small intestines
6 to 7 meters in length; diameter is 3 to 5
cm
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Small Intestine
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Blood supply: duodenum – right gastric,
supraduodenal, right gastroepiploic, superior and
inferior pancreaticoduodenal, hepatic and
gastroduodenal arteries mesenteric intestines:
superior mesenteric artery, via the jejunal and
ileal branches
Venous drainage: duodenum: splenic, superior
mesenteric, and portal veins mesenteric
intestines: superior mesenteric vein
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Duodenum
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Horseshoe shaped
Greek for “12 fingers”
30 cm long (12 fingers breadths); 3-5 cm in
width
Divided into 4 sections
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1st section - Duodenal “cap”
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Cone – 5 cm long
Base is continuous with pylorus
Lined with longitudinal mucosal folds
Most mobile segment of the small intestines
Enclosed in peritoneum which forms the
hepatoduodenal ligament; this ligament carries
the CBD
The most frequent site of peptic ulcers
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2nd section - duodenum
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10-12 cm long
Entirely retroperitoneum
Descends from L1 to L3
Intimately associated with the pancreas
Connects the “ampulla of Vater” – CBD
joins pancreatic ducts of Wirsung and
Santorini
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3rd section - duodenum
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Runs horizontally right to left
15 cm
At L3
Retroperitoneal
Lies directly over the descending aorta and
IVC
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4th section - duodenum
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8 cm long
Passes upward and forward, and to the left
of the aorta
Stays below the level of the body of the
pancreas
Terminates at the ligament of Treitz
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Jejunum and Ileum – Mesenteric
Small Intestines
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Longer in men than women – averages 5m
in length
No clear distention exists where the
jejunum and ends and the ileum begins
Proximal 2/5 is jejunum (Latin for “empty")
Distal 3/5 is ileum ( Greek for “roll” or
“twist”)
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Jejunum and Ileum – Mesenteric
Small Intestines
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Jejunum occupies LU ABD cavity
Ileum lies in the right abdomen and pelvis
Jejunum has a thicker wall and wider lumen
Ileum has more vascularity and fat in its
mesentery
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Jejunum and Ileum – Mesenteric
Small Intestines
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5 layers of the walls from
innermost to outermost:
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Mucosa
Submucosa
Muscularis
Subserosa
Serosa
Mucosa plica are lined
with Villi, which are lined
with microvilla
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Small Intestine
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The entire small intestines is composed of
an inner circular layer and an outer
longitudinal layer of non-straited muscle.
Thickest in the duodenum
The serosa is the visceral peritoneum,
which is an extension of the mesentery
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Mesentery
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Visceral Peritoneal
folds
Include:
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Mesentery of the small
intestines
Mesoappendix
Transverse mesocolon
Sigmoid mesocolon
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Contain:
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Blood vessels
Nerves
Lymph nodes
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Mesentery
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The root of the small intestine mesentery is
attached to the posterior wall of the abdominal
cavity
Begins at the level of L2 down to L4 or L5
Mesoappendix is a triangular fold that attaches
the whole length of the appendix to the lieal
mesentery, which carries the appendicular
vessels
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Colon
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Colon
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90 to 125 cm long; 2.5 to 8.5 in diameter
Segments:
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Cecum – proximal
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
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Colon Walls
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Innermost to outermost
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Mucosa
Submucosa
Muscularis
Serosa
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Colon functions
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Absorption of water and electrolytes
Compaction of fecal waste
Production of Vitamin K
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Colon Blood Supplies
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Cecum, ascending colon, right portion of
transverse colon are supplied from
ileocolic, right colic, and middle colic
branches of the SMA
Left transverse colon, descending colon,
sigmoid and rectum are supplied from the
superior left colic, sigmoid, and superior
(hemorrhoidal) branches of the IMA
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Colon
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Venous drainage is by accompanying veins
bearing the same names as the arteries
Lymphatic drainage is to the cisterna chyli
Innervation is from the celiac, superior
mesenteric, intermesenteric, superior and
inferior hypogastric plexuses, splanchnic
and tenth (vagus) cranial nerves an the 3rd
and 4th sacral segments
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Cecum
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Latin for “blind”
Wider (8.5 cm) than long (6.5 cm)
Ileum terminates at the superior aspect of
the cecum at the Ileocecal junction or valve
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Appendix
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Attached to the cecum
0.8 cm wide; averages 8.5 to 22.5 cm in
length
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Blood supply is from the mesoappendix
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Ascending Colon
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20 cm long
Extends from the ileocecal junction to the
hepatic flexure
Afixed retroperitoneally to the posterior
abdominal wall; interiorly with the ileum,
greater omentum, and anterior abdominal
wall
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Transverse Colon
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Begins at the hepatic flexure and crosses
the anterior abdomen in a upward curve
Attached to the diaphragm in the left
hypochondriac region at the 10th and 11th
ribs
The longest of the colon sections – 40 to 50
cm
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Descending Colon
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Begins at the splenic flexure down toward
the pelvis
30 cm long
Heaviest muscle layer and thinnest lumen
of the colon
Posterior aspect is intimately associated
with the posterior wall of the abdominal wall
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Sigmoid Colon
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15 to 50 cm long
Primary site for colon cancer
Most susceptible to volvulus
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Rectum
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Latin for “straight”
10 to 12 cm long
3 prominent interior folds, two on the left
wall, one on the right wall, that are referred
to as the valves of Houston
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Anus
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3 cm long
Musculature of involuntary and straited
tissues that form the anal sphincters
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Omenta
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Comprised of the lesser and greater omentum
The lesser omentum is continuous with the
peritoneum covering part of the stomach; attaches
to the lesser curvature of the stomach
The greater omentum is a double fold sheet
folded on to itself to form 4 layers; attaches to the
greater curvature of the stomach. Major site of fat
deposited in the abdomen
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Pancreas
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Elongated, flattened, grey to tan organ that
weighs between 70 and 120 g
Divided into head, neck, body, and tail
Head lies within the duodenal curve
Framework is divided into lobules consisting of
acini
Secretions break down fats, proteins,
carbohydrates, nucleic acids, other digestive
secretions, and sloughed epithelial cells; also
secretes bicarbonate that helps maintain a neutral
intraluminal pH
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Pancreas - Islets of Langerhans
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1,000,000 and account for only 1% of the mass of
the pancreas
Receives 25% of the blood supply
Consists of– alpha cells that secrete glucagon;
beta cells that secrete insulin; delta cells that
secrete somatostatin; PP or pacreatic peptide
secreting cells
Primary function is to maintain blood sugar levels
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Spleen
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Largest mass of lymphatic tissue
LUQ
Generally 12 cm long; 7 cm thick; 3-4 cm wide;
weighs 150 to 200 g
Made up of red pulp (vascular) 75% and white
pulp (lymph)
Primarily for filtration
Red pulp serves as RBC storage in youth; holds
35-80% of the adult’s platelets
Involved in immune response
Not absolute for survival
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Liver
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Largest organ in the abdomen
Weighs between 1,200 and 1,500 g; 2% of
the adult body weight
RUQ
Has a double blood supply; hepatic artery
carries 25% and all the oxygen the organ
requires; 75% from the portal vein that
provides the nutrients – hepatic vein drains
the liver which empties into the IVC
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Liver
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Porta hepatis – the point at which the hepatic
artery and the portal vein enter and the bile duct
exists
Common hepatic duct – the right and left hepatic
ducts meet at the porta hepatis
Provides metabolism of lipids, proteins,
carbohydrates, and hormones; store vitamins;
produce cytotoxins; degrade microorganisms,
drugs and endotoxins; harbor immunoglobulinproducing cells; secrets bile
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Biliary Tract
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Communicates between the liver and the
duodenum
Consists of the gallbladder, cystic duct,
CHD, CBD
Gallbladder lies in the interior surface of the
right hepatic lobe; attached to the liver at
the neck, which houses the cystic artery
and the cystic duct
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Biliary Tract
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The cystic duct connects the neck of the
GB to the CBD; .5 to 8cm long; connects
with the CHD to form the CBD
The CBD is formed at the junction of the
cystic and CHD; 5 to 7 cm long; ends at the
duodenum; joins the pancreatic duct to
form the ampulla of Vator at the duodenum;
the sphincter of Oddi controls the flow of
bile into the duodenum
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59
Abdominal Incisions
P 402-404 Table 14-3
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Types of incisions
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Vertical
Transverse
Oblique
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Muscle splitting
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A - Right upper
paramedian
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B - Left lower
paramedian
C - Right subcostal
 D - Transverse
 E – Pfannenstiel
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(Bikini)
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F – Upper median
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G – Lower median
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H – McBurney’s
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I – Right oblique
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J - Thoracoabdominal
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