STERILIZATION is a process by which an article, surface or medium is freed from all living micro organism either in the vegetative or spore state
The various agents used in sterilization can be classified as follows
a) physical agents:
1. sunlight
2. drying
3. dry heat : flaming, incineration, hot air
4. moist heat: pasteurization boiling, steam under normal pressure
5. filtration: candles,asbestos pads, membranes
6. radiation
7. ultrasonic and vibrations.
Chemical agents:
1. alcohols: ethyl isopropyl trichlorobutanol
2. aldehydes: formaldehyde, gluteraldehyde
3. dyes
4. halogens
5. phenols
6. surface active agents
7. metallic salts
8. gases
a)heat:
heat is a most reliable method of sterilization and shold be method of choice unless contraindicated. The factor influencing sterilization by heat
are:
1. nature of heat- dry heat or moist heat
2. temperature and time
3. number of micro organism present
4. characteristics such as species, strain, spring capacity
5. type of the material which the organism have to be eradicated
The killing effect of dry heat is due to protein denaturation, oxidative damage and the toxic effects of elevated levels of electrolytes.
The lethal effect of moist effect is due to denaturation and coagulation of protein
Dry Heat:
Flaming : inoculating loop of wire, the tip of the forceps and searing spatulas
Incineration : excellent method of safely destroying materials such as contaminated cloth, animal carcasses and pathological materials, plastics such as PVC
and polythene.
Hot air oven:
Most widely use dmethod of sterilization by dry heat
160c- for one hour- to sterilize glassware, forceps, scissors, scalpels, all glass syringes, swabs, some pharmeceutical products such as liquid
paraffin, dusting powder, fats and grease.
Monday, March 2, 2009
Hydrocele
It’s an abnormal collection of serous fluid in the tunica vaginalis of the testis or with in some part of the processes vaginalis.
Types :
Primary
Secondary
Primary hydrocele : The cause of, which is unknown.
Secondary hydrocele: When hydrocele is secondary to a disease in the testis and/or in the epididymis its usually small and lux.
a) Vaginal hydrocele
b) Encysted hydrocele of the cord
c) Infertile hydrocele
d) Congenital hydrocele
e) Funicular hydroceleis
f) Hydrocele of the canal of nuck
g) Hydrocele of hernial sac
h) Hydrocele in bisac
Symptom :
Swelling of the scrotum
Discomfort
Pain
Differential diagnosis :
Inguinal hernia
Haematocele
Pyocele
Filariasis of the scrotum
Cyst in relation to the epididymis
Encysted hydrocele of the cord
Tumors of the testis
Congenital hydrocele:
Congenital hydrocele in children is due to patent processus vaginalis. The opening of the processus vaginalis into the general peritaoneal cavity is
generally too small for the development of a hernia.through an inguinal incision, the processus vaginalis is dissected off. It is ligated and divided at the
neck and at the upper pole of the testis. The portion of the processus vaginalis within the inguinal canal is removed and the portion with the testis as
remains as tunica vaginalis.
Tapping :
This operation through not a radical treatment, is often indicated in case of old patients, who can well be tapped, which is painless, for a few
times for the rest of their lives.
While tapping, the position of the testis is ascertained by fingers and pushed posteriorly.
A wheal of local anaesthetic solution is raised in an area of the scrotal skin that is free of visible vessels and rather dependent. A fine Trocar
and a cannula are then trust into the sac through the scrotal wall.
The fluid is evacuated slowly to avoid shock. Once all the fluid has been evacuated, the cannula is withdrawn and the wound in the scrotal wall is
sealed with tinc iodine.
Injection treatment :
This treatment is not much practiced nowadays after tapping the hydrocele fluid 10ml of scleroscent solution (formed by combination of quinine
hydrochloride 2gm, Urethane 1gm in 15ml of water for injection of sodium tetradecyl solution) is injected into the cavity of tunica vaginalis. Gentle massage
is given to disperse the solution evenly. The scrotum is supported with a suspensory bandage. This treatment is necessary, may be repeated.
Jaboulay’s method of eversion of sac:
This radical method of operation is mostly practiced nowadays for small and medium size hydroceles. An incision is made on the scrotal wall, on the
side of the hydrocele. The incision is gradually depended till the tunica vaginalis is reached. In this process one will come across a few vessels which have
to be ligated. As soon as the tunica vaginalis is reached the sac is separated from the rest of the scrotal wall by finger. The sac is held in one hand and
with another hand the tunica vaginalis is incised. As soon as the incision is made fluid will come out of the sac. The two margins of the incisions are held
with two pairs of artery forceps and held upwards. The incision is extended upwards and down wards to allow the testis to come out through this opening. The
testis is brought out through the opening and the two margins of the tunica vaginalis are sutured behind the testis, so that the secreting surface of the
tunica vaginalis will be lying outside. Care must be taken not to strangle the testicular vessels. The scrotal wound is now sutured.
After dressing the wound, the patient should be instructed to wear suspensory bandage. Proper antibiotics should be administered. The stitches are
removed from the scrotal wall after 6days.
Lord’s procedure of excision of sac:
This operation is mainly indicated for big size hydroceles. The steps of operation is upto opening of te tunica vaginalis are same as those of the
previous mention nature of operation. The tunica vaginalis is now sutured with 10 to 12 catgut or Dexon sutures from the testis and the epididymis. When
these sutures are tied, the whole tunica is bunched at the edge of the testis.
Subtotal excision:
Complications :
Infection
Atrophy of the testis
Rupture
Haematocele
Hernia of the hydrocele sac
Calcification of the sac
Types :
Primary
Secondary
Primary hydrocele : The cause of, which is unknown.
Secondary hydrocele: When hydrocele is secondary to a disease in the testis and/or in the epididymis its usually small and lux.
a) Vaginal hydrocele
b) Encysted hydrocele of the cord
c) Infertile hydrocele
d) Congenital hydrocele
e) Funicular hydroceleis
f) Hydrocele of the canal of nuck
g) Hydrocele of hernial sac
h) Hydrocele in bisac
Symptom :
Swelling of the scrotum
Discomfort
Pain
Differential diagnosis :
Inguinal hernia
Haematocele
Pyocele
Filariasis of the scrotum
Cyst in relation to the epididymis
Encysted hydrocele of the cord
Tumors of the testis
Congenital hydrocele:
Congenital hydrocele in children is due to patent processus vaginalis. The opening of the processus vaginalis into the general peritaoneal cavity is
generally too small for the development of a hernia.through an inguinal incision, the processus vaginalis is dissected off. It is ligated and divided at the
neck and at the upper pole of the testis. The portion of the processus vaginalis within the inguinal canal is removed and the portion with the testis as
remains as tunica vaginalis.
Tapping :
This operation through not a radical treatment, is often indicated in case of old patients, who can well be tapped, which is painless, for a few
times for the rest of their lives.
While tapping, the position of the testis is ascertained by fingers and pushed posteriorly.
A wheal of local anaesthetic solution is raised in an area of the scrotal skin that is free of visible vessels and rather dependent. A fine Trocar
and a cannula are then trust into the sac through the scrotal wall.
The fluid is evacuated slowly to avoid shock. Once all the fluid has been evacuated, the cannula is withdrawn and the wound in the scrotal wall is
sealed with tinc iodine.
Injection treatment :
This treatment is not much practiced nowadays after tapping the hydrocele fluid 10ml of scleroscent solution (formed by combination of quinine
hydrochloride 2gm, Urethane 1gm in 15ml of water for injection of sodium tetradecyl solution) is injected into the cavity of tunica vaginalis. Gentle massage
is given to disperse the solution evenly. The scrotum is supported with a suspensory bandage. This treatment is necessary, may be repeated.
Jaboulay’s method of eversion of sac:
This radical method of operation is mostly practiced nowadays for small and medium size hydroceles. An incision is made on the scrotal wall, on the
side of the hydrocele. The incision is gradually depended till the tunica vaginalis is reached. In this process one will come across a few vessels which have
to be ligated. As soon as the tunica vaginalis is reached the sac is separated from the rest of the scrotal wall by finger. The sac is held in one hand and
with another hand the tunica vaginalis is incised. As soon as the incision is made fluid will come out of the sac. The two margins of the incisions are held
with two pairs of artery forceps and held upwards. The incision is extended upwards and down wards to allow the testis to come out through this opening. The
testis is brought out through the opening and the two margins of the tunica vaginalis are sutured behind the testis, so that the secreting surface of the
tunica vaginalis will be lying outside. Care must be taken not to strangle the testicular vessels. The scrotal wound is now sutured.
After dressing the wound, the patient should be instructed to wear suspensory bandage. Proper antibiotics should be administered. The stitches are
removed from the scrotal wall after 6days.
Lord’s procedure of excision of sac:
This operation is mainly indicated for big size hydroceles. The steps of operation is upto opening of te tunica vaginalis are same as those of the
previous mention nature of operation. The tunica vaginalis is now sutured with 10 to 12 catgut or Dexon sutures from the testis and the epididymis. When
these sutures are tied, the whole tunica is bunched at the edge of the testis.
Subtotal excision:
Complications :
Infection
Atrophy of the testis
Rupture
Haematocele
Hernia of the hydrocele sac
Calcification of the sac
INSERTION OF CHRONIC AMPULATORY PERITONEAL DIALYSIS
INSERTION OF CHRONIC AMPULATORY PERITONEAL DIALYSIS
Indications
1. Chronic ambulatory peritoneal dialysis is suitable for the majority of the patients with chronic renal failure
2. Patient in the remote areas distant from the heamodialysis
3. Any vascular diseases
4. Long term heamodialysis
5. Contraindicated to renal transplantation
6. After renal rejection
Contraindication:
Problems may be anticipated in the following group of patients those who have undergone :
1.Previous abdominal surgery where adhesions may obliterate the peritoneal cavity.
2.Those with large polycystic kidneys causing abdominal distention
3.Those with any abdominal hernias. These should be repaired before the insertion of peritoneal dialysis
4.A Cutanious Enterostomy or urinary diversion are relative but not absolute contraindication to peritoneal dialysis
Pre operative management
1. Staphylococcus aureus is an important pathogen and steps should be taken to identify and treat patients who are carriers of organism
2. Nasal and groin swabs are taken before surgery
Patient Preparation:
1. Position –Patient is positioned on the supine position
2. Anaesthesia—The Anaesthesia preferred is general anaesthesia or local anaesthesia
3. Skin preparation—determine the site of incision , begin the parts preparation, include area from the chest to mid thigh and down to the table at the
sides
4. Draping—four folded towels and a Laprotomy sheet
CAPD trolley
Procedure::
1. Under general anaesthesia, the abdomen is opened through the left or right lower paramedian incision of 2m length.
2. Anterior sheath is opened, rectus muscle is split open.
3. The peritoneum is opened for approximately 1cm or less.
4. Using a Roberts forceps the Oreopoulos catheter is inserted into the peritoneal cavity and positioned in the pelvis in front of the rectum but behind
the bladder ( uterus in women)
Wound Closure
1. The peritoneum is tightly closed around the catheter using a continous 2-0 chromic catgut suture the first of the two Dacron cuffs lying in the
muscle layer.
2. The final sutures may be placed through the cuff itself to encourage secure peritoneal closure this being facilitated by gentle traction on the
catheter . following peritoneal closure
3. Free inflow and drainage are tested using a saline filled syringe
4. The skin exit side is identified such that the second Dacron cuff lies 3cm away from the exit site is the subcutaneous tunnel; through a small stab
incision
5. A sharp plunger / introducer is pushed through the subcutaneocs tissues to the operative wound and the catheter is withdrawn
6. The rectus sheath is sutured with an absorbable suture eg. Dexon as is the deep fascia
7. The skin is sutured with 2-0 nylon
8. A titanium adaptor isintroduced into the end of the catheter and 5ml of dilute heparin solution (1000units/ml) are instilled into the catheter which
is the capped. Separate dressing are applied to the Laprotomy wound and exit site. The catheter is also taped to the skin to prevent excessive movement at
the exit site.
POST OPERATIVE CARE
The catheter should be flushed with 500ml dialysis solution.
Each day until CAPD is commenced. It is advisable to commence peritoneal dialysis 5-10 days after catheter insertion.
Earlier use of the catheter risks leakage of fluid around the catheter.
While a large interval may allow the intestine or omentum to become adherent to the catheter causing poor inflow or drainage.
The exist site dressing is changed daily using aseptic technique
Complication:
Failure of drainage is almost invariably caused by intestine or omentum wrapped around the catheter
Fluid leakage may manifest around the catheter
Pain and swelling into the anterior abdominal wall may occur due to the extravasation of fluid
Sepsis may develop around the cutaneous exit site. Antibiotics should be given.
Indications
1. Chronic ambulatory peritoneal dialysis is suitable for the majority of the patients with chronic renal failure
2. Patient in the remote areas distant from the heamodialysis
3. Any vascular diseases
4. Long term heamodialysis
5. Contraindicated to renal transplantation
6. After renal rejection
Contraindication:
Problems may be anticipated in the following group of patients those who have undergone :
1.Previous abdominal surgery where adhesions may obliterate the peritoneal cavity.
2.Those with large polycystic kidneys causing abdominal distention
3.Those with any abdominal hernias. These should be repaired before the insertion of peritoneal dialysis
4.A Cutanious Enterostomy or urinary diversion are relative but not absolute contraindication to peritoneal dialysis
Pre operative management
1. Staphylococcus aureus is an important pathogen and steps should be taken to identify and treat patients who are carriers of organism
2. Nasal and groin swabs are taken before surgery
Patient Preparation:
1. Position –Patient is positioned on the supine position
2. Anaesthesia—The Anaesthesia preferred is general anaesthesia or local anaesthesia
3. Skin preparation—determine the site of incision , begin the parts preparation, include area from the chest to mid thigh and down to the table at the
sides
4. Draping—four folded towels and a Laprotomy sheet
CAPD trolley
Procedure::
1. Under general anaesthesia, the abdomen is opened through the left or right lower paramedian incision of 2m length.
2. Anterior sheath is opened, rectus muscle is split open.
3. The peritoneum is opened for approximately 1cm or less.
4. Using a Roberts forceps the Oreopoulos catheter is inserted into the peritoneal cavity and positioned in the pelvis in front of the rectum but behind
the bladder ( uterus in women)
Wound Closure
1. The peritoneum is tightly closed around the catheter using a continous 2-0 chromic catgut suture the first of the two Dacron cuffs lying in the
muscle layer.
2. The final sutures may be placed through the cuff itself to encourage secure peritoneal closure this being facilitated by gentle traction on the
catheter . following peritoneal closure
3. Free inflow and drainage are tested using a saline filled syringe
4. The skin exit side is identified such that the second Dacron cuff lies 3cm away from the exit site is the subcutaneous tunnel; through a small stab
incision
5. A sharp plunger / introducer is pushed through the subcutaneocs tissues to the operative wound and the catheter is withdrawn
6. The rectus sheath is sutured with an absorbable suture eg. Dexon as is the deep fascia
7. The skin is sutured with 2-0 nylon
8. A titanium adaptor isintroduced into the end of the catheter and 5ml of dilute heparin solution (1000units/ml) are instilled into the catheter which
is the capped. Separate dressing are applied to the Laprotomy wound and exit site. The catheter is also taped to the skin to prevent excessive movement at
the exit site.
POST OPERATIVE CARE
The catheter should be flushed with 500ml dialysis solution.
Each day until CAPD is commenced. It is advisable to commence peritoneal dialysis 5-10 days after catheter insertion.
Earlier use of the catheter risks leakage of fluid around the catheter.
While a large interval may allow the intestine or omentum to become adherent to the catheter causing poor inflow or drainage.
The exist site dressing is changed daily using aseptic technique
Complication:
Failure of drainage is almost invariably caused by intestine or omentum wrapped around the catheter
Fluid leakage may manifest around the catheter
Pain and swelling into the anterior abdominal wall may occur due to the extravasation of fluid
Sepsis may develop around the cutaneous exit site. Antibiotics should be given.
SPINAL ANAESTHESIA
a) spinal anaesthesia is the simpler, easier, cheeper technique
b) it is applied between L2-L3 (or) L3-L4 space of the sub- arachnoid space and the center of action is the caude equina rather than spinal cord.
Things required:
25-27g needle
bupivacine
fentanyl
lignocaine jelly
position
seated
procedure
1.In the seated position the injectable local anaesthetics 1%lignocaine jelly is applied at the selected point.
3. After 30sec the spinal needle is injected over the L2-L3 (or) L3-L4 region
4. check for the flow of CSF
5. withdraw the needle immediately if patient complaint of shooting pain
6. fix the needle and attach the syringe containing drug and inject over 15 sec
Factors affecting spread of drug:
1.Gravity:
The position of patient in the 1st 15mm is important as the hyperboric solution spread is markedly influenced by gravity
2.Speed of injection
3.drug volume
level of block required
volume should be reduced in pregnancy and obesity
4.age has no significant correlation
b) it is applied between L2-L3 (or) L3-L4 space of the sub- arachnoid space and the center of action is the caude equina rather than spinal cord.
Things required:
25-27g needle
bupivacine
fentanyl
lignocaine jelly
position
seated
procedure
1.In the seated position the injectable local anaesthetics 1%lignocaine jelly is applied at the selected point.
3. After 30sec the spinal needle is injected over the L2-L3 (or) L3-L4 region
4. check for the flow of CSF
5. withdraw the needle immediately if patient complaint of shooting pain
6. fix the needle and attach the syringe containing drug and inject over 15 sec
Factors affecting spread of drug:
1.Gravity:
The position of patient in the 1st 15mm is important as the hyperboric solution spread is markedly influenced by gravity
2.Speed of injection
3.drug volume
level of block required
volume should be reduced in pregnancy and obesity
4.age has no significant correlation
EPIDURAL ANAESTHESIA
The epidural space is a low pressure space between the ligamentum flavum and the duramatter occupied by areolar tissue, loose fat and internal
vertebral venous plexus.
Located at the level of L3 –L4
Apparatus required:
16/18G toony needle
23/27G needle
Sensocaine
Procedure
• inject the 2% lignocaine jelly at the selected point to provide local anaesthesia
• wait 30 sec for lignocaine to act
• insert the epidural needle through the supra sinous ligament
• attaching a syringe with 7mi of saline and holding the hub of the needle firmly. Push the needle inwards steadily and continuosly and the needle
enters the epidural space with the saline flowing in freely
• avoid going beyond 5cm marking in the needle as the sub arachnoid space is likely to be entered.
• Then place the catheter after checking it the filter by flushing with the saline
• Insert the catheter up to 15-20-cm
• Push the catheter in while removing the needle to prevent it being pulled out
• Then the catheter is withdrawn to 8-10cm and the filter is connected
• Test dose is administered to identify whether the catheter or needle is in IV or sub-arachnoid space
Drugs :
1. Bupivaccine 0.5% for anaesthesia and 0.1 –0.25% for analgesic
2. Fentanyl 2 to improve the quality of analgesia
3. Morphine and diamorphine to prolong the duration of analgesia
Volume
1. Depends upon the distance between the point of injection and the site of surgery
2. volume should be reduced in elderly obesity and pregnancy.
vertebral venous plexus.
Located at the level of L3 –L4
Apparatus required:
16/18G toony needle
23/27G needle
Sensocaine
Procedure
• inject the 2% lignocaine jelly at the selected point to provide local anaesthesia
• wait 30 sec for lignocaine to act
• insert the epidural needle through the supra sinous ligament
• attaching a syringe with 7mi of saline and holding the hub of the needle firmly. Push the needle inwards steadily and continuosly and the needle
enters the epidural space with the saline flowing in freely
• avoid going beyond 5cm marking in the needle as the sub arachnoid space is likely to be entered.
• Then place the catheter after checking it the filter by flushing with the saline
• Insert the catheter up to 15-20-cm
• Push the catheter in while removing the needle to prevent it being pulled out
• Then the catheter is withdrawn to 8-10cm and the filter is connected
• Test dose is administered to identify whether the catheter or needle is in IV or sub-arachnoid space
Drugs :
1. Bupivaccine 0.5% for anaesthesia and 0.1 –0.25% for analgesic
2. Fentanyl 2 to improve the quality of analgesia
3. Morphine and diamorphine to prolong the duration of analgesia
Volume
1. Depends upon the distance between the point of injection and the site of surgery
2. volume should be reduced in elderly obesity and pregnancy.
REGIONAL ANAESTHESIA
Local anaestehsia provide excellent preoperative anaesthesia and analgesia.
Local anaestehsia is defimed as the reversible loss of sensation to a restricted region of the body.
It is caused by the blockage of sensory nerve endings and conduction block
Spinal and epidural anaesthesia
Advantages:
1. Minimizes the stress
2. Provides both pre and post operative analgesic
3. reduce bleeding
4. effective muscle relaxation
5. safe recovery
6. Cheaper
Contra indication
1. sepsis at the size of injection
2. bleeding disorders
3. anticoagulant theraphy
4. hypovolaemia
5. hypertension
6. previous spinal injury
7. systemic sepsis
preoperative assessment
1. patient should be free from spinal abnormalities eg. Hyposcoliosis, skin incision etc
2. evaluation of coagulopathy and anticoagulopathy theraphy
3. informed consent
procedure:
1. Rapid intravenous infusion of saline
2. monitor the pulse, NIBP, heart rate and SPO2
precaution:
1. proper scrubbing of hands
2. gloves must be sterile
3. paintaing of skin with antibiotic should be done
position:
1. seated position
Local anaestehsia is defimed as the reversible loss of sensation to a restricted region of the body.
It is caused by the blockage of sensory nerve endings and conduction block
Spinal and epidural anaesthesia
Advantages:
1. Minimizes the stress
2. Provides both pre and post operative analgesic
3. reduce bleeding
4. effective muscle relaxation
5. safe recovery
6. Cheaper
Contra indication
1. sepsis at the size of injection
2. bleeding disorders
3. anticoagulant theraphy
4. hypovolaemia
5. hypertension
6. previous spinal injury
7. systemic sepsis
preoperative assessment
1. patient should be free from spinal abnormalities eg. Hyposcoliosis, skin incision etc
2. evaluation of coagulopathy and anticoagulopathy theraphy
3. informed consent
procedure:
1. Rapid intravenous infusion of saline
2. monitor the pulse, NIBP, heart rate and SPO2
precaution:
1. proper scrubbing of hands
2. gloves must be sterile
3. paintaing of skin with antibiotic should be done
position:
1. seated position
BLADDER NECK INCISION
ANTIBIOTIC:
Inj. Gentamycin 80mg
Anaesthesia :
Under spinal anaesthesia/ epidural anaesthesia
Position :
Patient is positioned on the table in a comfortable position
Skin preparation:
Usually cleaned with an antimicrobial solution (eg.betadine solution)
Begin at the umbilical region, covering at the pubic area, the inner thighs up to the anus.
Draping :
1 drape sheet under the buttocks
2 leggings, one for each leg
1 drape sheet over the andomen
Instrument :
• Cystoscopy sheath 22fr
• Bridge
• 30-degree telescope
• 0 degree telescope
• Cystoscopy sheath / BNI sheath (24fr / 26fr)
• Working element / resectoscope (forward moving finger grip) BNI knife
• Ball electrode
• Cable for resection
• Ellick evacuator
• Light source cable
• Camera
• Irrigation source / Y-connection
Miscellaneous things:
1. disposable syringe
2. xylocaine jelly 2%
3. foleys catheter 3 way
4. urobag
5. catheter introducer
6. normal saline
7. urethral dilators
urological procedure:
1. The objective is toproduce a single incision in the 7 0’clock position from just below the right ureteric orifice to alongside the vermontanum,
completely dividing all bladder neck fibres in the line of the incision through to the outer part of the capsule
2. the micro video operating system is particularly useful for this operation due to the magnified image on the video monitor, which encourage very
gentle strokes of the electrode as the bladder neck fibres pull apart
3. apply 2%xylocaine jelly per-urethrally
4. take the cystoscopy sheath 22fr and make the following connections
connect the bridge to the cystoscopy sheath
• insert the 30 degree telescope inside the cystoscopy sheath
• connect endo-camere to the telescope
• connect the light source to cystoscopy sheath
• connect the irrigation source
5. after all the connections have been made, the cystoscopy sheath will all the connections is inserted per-urethrally
6. visualize the urethra / vermontaneum / bladder and ureteric orifices.
7. remove the cystoscopy sheath and all the connections.
8. sometimes it may be required to dilate the urethra up to 26fr with the help of metal dilators for easy passage of the BNI sheath.
9. next the BNI cystoscopy sheath either 24fr (intermittent irrigation) / 26fr (continuous irrigation) is chosen depending on the surgeons choice, is
introduced per urethrally and its obturator is removed and the bladder emptied.
10. to the working element or the resectoscope the following connections are made.
• BNI knife / Collings knife
• 30 degree telescope
• Endocamera
• Light source
• Diathermy cable
11. the working element with the above connections are inserted through the 24 fr / 26 fr BNI sheath
12. the ureteric orifices are carefully identified with particular attention to the distances from the bladder neck.
13. the position of the verumontaneum is noted together wth the topography of any prostatic adenoma, which may influence theline of resection.
14. the bladder neck has the appearance of a wall of tissue preventing direct inspection of the bladder base.
15. the incision is started cautiously in the 7 0’clock position, just inside the internal urinary meatus, dividing the mucosa and exposing the bladder
neck fibres.
16. as the incision is deepened the bladder neck fibres can be seen to spring apart revealing further layers. They are progressively divided at this
level by delicate diathermy incision until the capsule is reached
17. this may be recognized by the sudden transition of a glistening translucent cobweb appearance to accompanying small globules fat
18. the incision is finally extended proximally to just below the right ureteric orifice and distally to alongside the verumontaneum
19. it should now be possible to view the base of the bladder vessels, which should be carefully sealed with the help of diathermy
20. if the mucasal bleeding troublesome this may be conviently dealt with a roller ball electrode
21. next remove the working element will all connections leaving the BNI sheath per urethrally
22. with the help of the ellick’s evacuator connected to the sheath, a bladder wash is done to remove clots
23. then put in the obturator and remove the BNI sheath
24. a 3 way urethral catheter is inserted per urethrally with the help of a catheter introducer ( 3-way for irrigation)
25. irrigation can be removed either on the 1st or 2nd post operative day depending on the patients condition.
Inj. Gentamycin 80mg
Anaesthesia :
Under spinal anaesthesia/ epidural anaesthesia
Position :
Patient is positioned on the table in a comfortable position
Skin preparation:
Usually cleaned with an antimicrobial solution (eg.betadine solution)
Begin at the umbilical region, covering at the pubic area, the inner thighs up to the anus.
Draping :
1 drape sheet under the buttocks
2 leggings, one for each leg
1 drape sheet over the andomen
Instrument :
• Cystoscopy sheath 22fr
• Bridge
• 30-degree telescope
• 0 degree telescope
• Cystoscopy sheath / BNI sheath (24fr / 26fr)
• Working element / resectoscope (forward moving finger grip) BNI knife
• Ball electrode
• Cable for resection
• Ellick evacuator
• Light source cable
• Camera
• Irrigation source / Y-connection
Miscellaneous things:
1. disposable syringe
2. xylocaine jelly 2%
3. foleys catheter 3 way
4. urobag
5. catheter introducer
6. normal saline
7. urethral dilators
urological procedure:
1. The objective is toproduce a single incision in the 7 0’clock position from just below the right ureteric orifice to alongside the vermontanum,
completely dividing all bladder neck fibres in the line of the incision through to the outer part of the capsule
2. the micro video operating system is particularly useful for this operation due to the magnified image on the video monitor, which encourage very
gentle strokes of the electrode as the bladder neck fibres pull apart
3. apply 2%xylocaine jelly per-urethrally
4. take the cystoscopy sheath 22fr and make the following connections
connect the bridge to the cystoscopy sheath
• insert the 30 degree telescope inside the cystoscopy sheath
• connect endo-camere to the telescope
• connect the light source to cystoscopy sheath
• connect the irrigation source
5. after all the connections have been made, the cystoscopy sheath will all the connections is inserted per-urethrally
6. visualize the urethra / vermontaneum / bladder and ureteric orifices.
7. remove the cystoscopy sheath and all the connections.
8. sometimes it may be required to dilate the urethra up to 26fr with the help of metal dilators for easy passage of the BNI sheath.
9. next the BNI cystoscopy sheath either 24fr (intermittent irrigation) / 26fr (continuous irrigation) is chosen depending on the surgeons choice, is
introduced per urethrally and its obturator is removed and the bladder emptied.
10. to the working element or the resectoscope the following connections are made.
• BNI knife / Collings knife
• 30 degree telescope
• Endocamera
• Light source
• Diathermy cable
11. the working element with the above connections are inserted through the 24 fr / 26 fr BNI sheath
12. the ureteric orifices are carefully identified with particular attention to the distances from the bladder neck.
13. the position of the verumontaneum is noted together wth the topography of any prostatic adenoma, which may influence theline of resection.
14. the bladder neck has the appearance of a wall of tissue preventing direct inspection of the bladder base.
15. the incision is started cautiously in the 7 0’clock position, just inside the internal urinary meatus, dividing the mucosa and exposing the bladder
neck fibres.
16. as the incision is deepened the bladder neck fibres can be seen to spring apart revealing further layers. They are progressively divided at this
level by delicate diathermy incision until the capsule is reached
17. this may be recognized by the sudden transition of a glistening translucent cobweb appearance to accompanying small globules fat
18. the incision is finally extended proximally to just below the right ureteric orifice and distally to alongside the verumontaneum
19. it should now be possible to view the base of the bladder vessels, which should be carefully sealed with the help of diathermy
20. if the mucasal bleeding troublesome this may be conviently dealt with a roller ball electrode
21. next remove the working element will all connections leaving the BNI sheath per urethrally
22. with the help of the ellick’s evacuator connected to the sheath, a bladder wash is done to remove clots
23. then put in the obturator and remove the BNI sheath
24. a 3 way urethral catheter is inserted per urethrally with the help of a catheter introducer ( 3-way for irrigation)
25. irrigation can be removed either on the 1st or 2nd post operative day depending on the patients condition.
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