SUR 111

Tracheotomy/TracheostomyAppendectomy

TracheotomyTracheostomy

Tracheotomy/Tracheostomy• Tracheotomy temporary opening into the trachea

to facilitate breathing • Tracheostomy permanent opening of the trachea

and creation of a tracheal stoma• Must place tracheal tube with either• Patient will be hooked up to a ventilator• Long term tracheostomy may eventually be able to

wean off ventilator, but maintain stoma that will function as their nose did prior to surgery

• Tracheostomy is indicated for a patient who requires emergent or elective airway management for:– prolonged ventilator dependence – acute upper airway obstruction– chronic upper airway obstruction

Pathology for Tracheotomy or Tracheostomy

• Vocal cord paralysis• Neck surgery• Trauma• Prolonged intubation• Secretion management• Cannot intubate• Stridor due to tracheal blockage• Sleep apnea

Anatomy of the Neck

(From Potter PA and Perry AG: Fundamentals of nursing, ed 5, St Louis, 2001, Mosby.)

Anatomy of the Larynx

Anterior view of the pharynx

Posterior view of the pharynx

(From Thibodeau GA and Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby.)

http://upload.wikimedia.org/wikipedia/commons/d/d4/Illu01_head_neck.jpg

Anesthesia

• General• Local

Medications

• Local anesthetic: Lidocaine or bupivicaine with or without epinephrine

• Antibiotic irrigation

Positioning

• Supine• Shoulder roll• Donut headrest• Pillow under knees• Safety strap

Prep

• End of chin to midchest and bedsheet to bedsheet

• Prep of choice: Duraprep, betadine scrub and/or paint

Draping

• Towels • Small fenestrated sheet (Pediatric lap sheet)

Supplies, Equipment, Instruments

• Minor basin• Basic pack• Pediatric lap sheet• Other small fenestrated

sheet• Blades • Suture or ties of surgeon’s

choice (prn)

• Tracheotomy tray• Tracheotomy tube

(Shiley)• Twill tape

Surgical Procedures• Tracheotomy/Tracheostomy

Isthmus of thyroid is divided to expose

the trachea

Tube is insertedTwo tracheal rings are cut, and the upper ring is

partially resected. Tracheal hook pulls the trachea from the depth of the

wound toward the surface

(Modified from DeWeese DD: Textbook of otolaryngology, ed 6, St Louis, 1982, Mosby.)

Operative Sequence

• Discussion• http://video.google.com/videoplay?docid=261546049131841443&q=t

racheostomy&total=37&start=0&num=10&so=0&type=search&plindex=0

Considerations

• Will make sure obturator goes with patient to PACU or ICU

• Complications: hemorrhage, infection, damage to other structures

Large Intestine (Colon) Anatomy

Look to page 395-404 in ST

• Appendectomy – Removal of the appendix

• Appendicitis– Inflammation/infection of the appendix– Acute condition– Urgent procedure

• Becomes emergent procedure if ruptures– Rupture leads to peritonitis which untreated leads to death

• Sometimes Removed as Prophylactic Procedure (Incidental Appendectomy) in addition to other lower abdominal surgical procedures

• Laparoscopic Appendectomy

The base of the mesoappendix is coagulated using the endocoagulator

(From Goldberg JM and Falcone T: Atlas of endoscopic techniques in gynecology, Philadelphia, 2001, Saunders.)

• The appendix is attached to the mesoappendix, which is divided with scissors or ESU and ligated with vessel clips or surgical stapler

• Laparoscopic Appendectomy, continued

(From Goldberg JM and Falcone T: Atlas of endoscopic techniques in gynecology, Philadelphia, 2001, Saunders.)

The endo-loop is tightened at the base of the appendix

• Once the appendix is mobilized, it can be amputated from the cecum

• Two ties must be placed around the appendix between the lines of amputation

• Laparoscopic Appendectomy, continued

(From Goldberg JM and Falcone T: Atlas of endoscopic techniques in gynecology, Philadelphia, 2001, Saunders.)

The appendix is excised with scissors

• The appendix is then transected with the ESU, scissors, or surgical stapler

• The stapler provides additional security against leakage

• The specimen is brought out of the abdomen with a specimen retrieval bag

• Loop technique: http://www.dailymotion.com/video/x403wh_lap-appendectomy_tech

• Stapler technique: http://www.dailymotion.com/video/x4046e_lap-appendectomy-with-stapler_tech