Table of contents :

tissue explants, ablations and shapings head surgery neurosurgery oral and maxillofacial surgery thoracic surgery cardiovascular surgery cardiac surgery vascular surgery respiratory surgery abdominal surgery gastrointestinal surgery genital surgery male genital surgery female genital surgery obstetric surgery urinary surgery orthopedic surgery biopsies

tissue substitutions or grafts orthoses prostheses plastic surgery bibliography web resources

• general surgery : that which deals with surgical problems of all kinds, rather than those in a restricted area, or in a surgical specialty such as neurosurgery.
• major surgery : surgery that is particularly difficult or hazardous.
• major operation : an operation of major surgery
• minor surgery : surgery restricted to the management of minor problems and injuries.
• minor operation : an operation of minor surgery
• ambulatory surgery : an operative procedure, performed either in a hospital or in a freestanding facility, that does not require an overnight stay in a hospital.
• general features
• evaluation of general conditions
• multifactorial indexes of cardiac risk in noncardiac surgical procedures :
• Goldman criteria^ref
• class I : 0-5 => risk = 1%
• class II : 6-12 => risk = 7%
• class III : 12-25 => risk = 14%
• class IV : > 25 => risk = 70%
• Detsky criteria^{ref1, ref2}
• Larsen index
• American Society of Anesthesiologists (ASA) classification
• class I : healthy patient
• class II : mild systemic disease with no functional limitation  - for example, chronic bronchitis, moderate obesity, controlled diabetes mellitus, past acute myocardial infarction or moderate systemic arterial hypertension
• class III : severe systemic disease with definite functional limitation - for example, controlled angina pectoris, insulin-dependent diabetes mellitus, severe obesity, moderate respiratory failure
• class IV : severe systemic disease that is a constant threat to life - for example, unstable angina unresposive to therapy, severe heart failure, advanced respiratory, renal liver or endocrine failure
• class V : moribund patient who is not expected to survive for 24 hours with or without surgery - for example, with an abdominal aortic aneurysm, severe polytrauma
• suffix E : emergency procedure
Risk factors for postoperatory complications :
• age and age-associated diseases (newborns and elderlies) : investigate respiratory, cardiac and metabolic functions
• respiratory diseases and tobacco smoking : eradications of acute infections and control of chronic infections with bronchodilators, respiratory physiotherapy, mucolytics, hydratation, cessation of smoking. Make CXR, spirometry and ABG
• cardiovascular diseases : posteroanterior and laterolateral CXR, EKG. Higher mortality in NYHA class III/IV patients
• diabetes mellitus
• obesity
• drugs : suspend MAOI at least 2 weeks before surgery, shift from oral anticoagulants to heparin
• estroprogestins
• malnutrition
• liver failure
• renal failure
• shock
• neoplasms
• iatrogenic immunodepression (radiotherapy, chemotherapy, GR agonists)
• previous infections
• coagulopathies
High-risk patients :
• recent unvoluntary weight loss > 10% of usual body weight
• albuminemia < 3,5 g/dl;
• anergy at skin tests
• total lymphocyte count < 1500/mm³
• prevention of postoperatory complications
• antiseptic surgery : surgery done using antiseptic principles
• aseptic surgery : surgery performed with aseptic techniques

Joseph Lister first used antiseptical gauzes, then industrially produced by Johnson. A certain degree of contamination during surgery is unavoidable.
• operating-theatre :
• environmental cleanse
• adequate venitlation : air contamination is the most dangerous as it allows direct contamination of injuries
• access dilution and control (only strictly useful persons should be admitted to operating-theatre)
• patient :
• skin preparation
• trichotomy as nearer to the surgery as possible, by using razor and depilating cream to prevent abrasions that would increase germ penetration
• skin high-level disinfection (HLD) with povidone-iodine (PVP-I) (Betadine^®) (preferred over iodine tincture due to lower iodine skin penetration, slower evaporation (lesser heat loss), less irritation and flammability; anyway alcoholic solutions can remove skin lipid layer with bound germs, but this is also a protective layer for more aggressive germs)
• sterile linens
• trained operating-theatre personnel
• washing
• personal protection equipment (gloves, whitecoats, ...)
• disposable paper linen increases costs but decreases far more contamination. Threads released by cotton material could obstruct ventilation probes.
• surgeons
• clean clothes
• operating-theatre-restricted shoes or overshoes
• cap and mask before coming into operating-theatre
• hand and forearm washing
• paper whitecoat and gloves (they usually can't resist more than 2.5 hours of surgery)
• kinds of surgical operations
• class I : clean surgery
• no inflammation or infection encountered
• non-traumatic wound : trauma cause retention, hematoma, and tissue necrosis, an ideal pabulum for germ proliferation
• no breaks in sterile technique
• no drainage : in clean surgery blockage of secretion drainage is the leading cause of sepsis
• no opening of secretory channels potentially causing sepsis (respiratory, alimentary (gastrointestinal, biliary or oropharyngeal) and urogenital tracts : the urogenital tract can normally be sterile)
Wound infection rates without prophylaxis are usually < 2%. Airborne, exogenous micro-organisms are usually involved. Prophylaxis should be given only when: (a) infection would have catastrophic results (e.g. heart valve or joint replacements); or (b) a risk index or some other information indicates an increased probability of postoperative wound infection.
Examples of clean surgical procedures include, but are not limited to, the following:
• adrenalectomy
• op.muscle, fascia, tendons
• cardiac
• orchiopexy
• cesarean section-elective
• orthopedics (reconstructive)
• ear surgery
• pancreatic surgery
• eye surgery
• plastic surgery
• herniorrhaphy
• splenectomy
• laparotomy (bowel not entered)
• thyroid/parathyroid surgery
• mastectomy (uninflammed)
• tubal/ovarian
• neurosurgery
• vascular surgery
Placement :
• patients in this category may room with each other
• may be placed with patients at high risk for acquiring infection and other types of non-surgical patients. A post-op hernia patient could be placed with a brittle diabetic
• may be placed with clean-contaminated (Class II) patients if necessary. For example: A patient s/p Lap Chole could be placed  with a mastectomy patient
• do not place with contaminated or dirty surgery cases
• class II : clean-contaminated surgery : clean, but endogenous flora is involved
• gastrointestinal, genitourinary, and/or respiratory tracts entered under controlled conditions; no significant spillage or unusual contamination occurs.
• a non-traumatic wound; no inflammation encountered.
• a minor break in sterile technique occurred
• re-operation of clean surgery within 7 days
• procedures following blunt trauma
Postoperative infection rates without prophylaxis range from 5 to 25%, and endogenous flora are commonly involved
Examples of clean-contaminated surgical procedures:
• appendectomy (incidental) -no inflammation or pus  seen
• hysterectomy or hysterotomy
• bowel resection -(no spillage into peritoneal cavity)
• lung surgery - (no infection seen)
• bladder and ureteral surgery
• nose/throat/laryngectomy
• cholecystectomy /lap chole (elective)
• suprapubic prostatectomy
• cesarean section-after trial labor
• vaginal hysterectomy
• vag delivery-PROM< 24hr.
• hemorrhoidectomy
• therapeutic abortion
• dental surgery
• gastrectomy
• D and C
• TraCh
• TURP
Placement :
• patients in this category may be placed together.
• may be placed with patients at high risk for acquiring infection and other types of non-surgical patients.
• may be placed with clean surgery patients.
• do not place with contaminated or dirty patients.
• class III : contaminated surgery : has increasing chance for postoperative infectious complications. The operatory field contains potentially septic tissues (expecially due to the basal disease for which the patient undergoes surgery). Anaerobic bacteria (Bacteroides spp., Clostridium spp., ...).
• acute nonpurulent inflammation seen
• operations with major breaks in sterile techniques.
• gross spillage from GI tract occurs (gastrointestinal content or bile)
• the GU or biliary tracts are entered in the presence of infected bile or urine
• traumatic wound < 4-8 hours old from a relatively clean source.
Infection rates without prophylaxis range from 15 to 40%.
Examples of Class III surgical procedures include, but are not limited to:
• appendicectomy in acute appendicitis
• opening of biliary tract in acute cholecystitis
• incision and drainage of abscess
• gun shot wound (fresh, without perforated bowel)
• rectal surgery
• TUR or suprapubic prostatectomy with positive pre-op urine culture.
• vaginal or cesarean section deliveries with PROM 24 hours.
Placement : patients in this category may be placed together.
Prevention : mechanical cleaning, washing, antibiotic therapy
• class IV : dirty surgery : existing acute bacterial infection or a perforated viscera is encountered  (clean tissue is transected to gain access to pus = higher bacterial load).
• traumatic wound-old (4 < hours < 24) with retained devitalized tissue
• fecal contamination, foreign body or retained, devitalized tissue is present.
Postoperative infection rates in this group exceed 40%. The use of antimicrobials in dirty and some contaminated procedures is not classified as prophylaxis but as treatment for a presumed infection.
Examples include but are not limited to :
• incision and drainage of abscess or debridement of wound
• reduction of compound fractures
• visceral perforation
• ruptured appendix
• amputation of gangrenous extremity
• exploratory lap with peritonitis found
• penetrating trauma
Placement :
• patients in this category may be placed together, unless otherwise indicated as in the disease-specific precautions table.
• do not place with surgical patients in any other category.
• do not place with immunocompromised patients.
• may place with non-surgical patients who are not immunocompromised, if there is no drainage.
Prevention : antibiotics after surgery, reduce the time lapse between onset of inflammation and surgery
Surgical infections represent 7% of all hospital admissions (300,000 per year) :
• urinary apparatus (40%)
• surgical wound infection (27%) : infected surgical wounds require reopening, with worsening of aesthetic results
• respiratory apparatus (17%)
• other (17%)
• phlebitis
• deep vein
• superficial veins used for cannulations
Surgical site infections :
• superficial infection : skin, subcutis
• deep infection : fascia and muscles
• organ space infection
Factors affecting surgical infections :
• kind of surgery

	percentage of total		infection rate
	NAS-NRC	Foothills H	NAS-NRC	Foothills H
total	15,613	62,937	7.4%	4.7%
clean	74.8%	75%	5.1%	1.5%
clean-contaminated	16.6%	15%	10.8%	7.7%
contaminated	4.3%	7%	16.3%	15.2%
dirty	3.7%	3%	28%	40%

• bacteria-related factors :
• at least 10⁵ microorganisms
• surface flora components
• exotoxins
• local factors :
• foreign body (e.g. firearm wound deepening skin germs into tissues)
• ischemia
• patient-related factors
• pain and hypothermia => vasoconstriction => local hypoxia
• uremia
• corticosteroids (suspend corticosteroids before surgery)
• advanced age
• diabetes mellitus : only normoglycemic patients can be operated
• malignant tumour
• anticoagulants and antiplatelet drugs
Catabolic fever early after surgery is due to resorption of necrotic tissues into bloodstream and negative nitrogen balance. Sepsis should be supspected if fever lasts for > 3 days or is higher than 37.8°C (usually 39°C). Drug reaction fever, post-traumatic fever, and atelectasis-induced fever are other differential diagnoses
Source :
• surgical wound (deiscence of anastomoses at day 7-8 marked by outflow of material from drainage)
• catheters (mainly urinary, but also oropharyngotracheal catheters)
• phlebitis (compare lower limbs, expecially calves)
• respiratory problems (related to duration of lying in bed; despite limitations imposed by pain and nasogastric probe, patient should try to make deep breathes to prevent pulmonary stasis, which otherwise could cause virulentation of gall-bladder bacteria : sometimes prophylactic cholecystectomy if practiced before major surgery)
Symptoms & signs : tachycardia, signs of local inflammation
Prevention : many surgical conditions are primarily infective and the prevention of the spread of infecting organisms to other patients is a cause of constant anxiety. General principles :
• general measures of hygiene are of the first importance for the patient and the nurse. Cleanliness of the ward, the handling of food, crockery, and personal cleanliness are of the greatest importance. An individual thermometer for each patient commonly stored dry after wiping with a Mediswab is an example of the type of measure which it is necessary to take
• control of special local conditions in a surgical wound. Injury or bruising of a wound increases the risk of infection. The patient is instructed not to touch dressings or his skin which may have been contaminated by pus. Hand-washing should be frequent and an anti-bacterial soap is used. Masks should not be touched with the fingers, changed frequently and as soon as a dressing has been finished discarded so that the nurse is able to breathe freely and diminish the risk of infection into her own nose.
• special methods of protection such as immunisation and antibiotic prophylaxis to reduce bacterial load (not sterilization) thanks to adequate concentration in operatory field blood and reducing pathogenic microflora of the targeted organs. Number of administrations depends on duration of surgery and drug half-life. Antibiotic should be present in the target tissues at the time of incision and when contamination occurs. The duration of such treatment is commonly 3 to 5 days. The optimum timing for prophylaxis by parenteral administration is at the time of induction of anaesthesia. The infection rate increases if antibiotics are given > 2 hours preoperatively or are delayed until after the start of the operation. For the majority of procedures lasting for 2 hours or less, a single dose of prophylactic antibiotic is sufficient : ecessively long courses of ‘prophylactic’ antibiotic, whether before or after surgery, select for resistant organisms and may increase the risk of infection and the practice of continuing antibiotics until such time as surgical drains have been removed is unproven and not recommended. For procedures lasting > 2 hours, or when there is massive blood loss producing antibiotic ‘wash-out’, 1 or 2 further doses may be required. The antibiotics chosen for prophylaxis should have spectra of activity that include those organisms most likely to cause infection following the procedure. It is not necessary for the chosen agent to ‘cover’ all the likely contaminants. The benefits of prophylaxis should outweigh the risks, e.g. the antibiotic should be safe and should not contribute to the emergence of antibiotic-resistant bacteria. Since antibiotic prophylaxis accounts for at least 33% of all antibiotics used in hospital practice, the issues of antibiotic costs and cost-effective prophylaxis are becoming increasingly important. Prophylactic antibiotics are only one factor that determines the risk of infection. Other factors of equal or even greater importance are surgical technique, the duration of surgery, the duration of preoperative stay, shaving the operation site (if this must be done, shave immediately preoperatively), repeat surgical procedure, obesity, immune compromise and a variety of other host factors.

surgical operation	main bacteria involved in postoperatory infections	antibiotic(s)	route of administration
clean surgery (prostheses and other)	Staphylococcus aureus, coagulase-negative staphylococci (CNS), Enterobacteriaceae (aorto-coronary bypass surgery, prosthetic vascular surgery with inguinal and lower limbs involvement)
head and neck surgery (clean-contaminated/contaminated). Antibiotic prophylaxis is not recommended in:  ear surgery (clean) head and neck surgery (clean) nose or sinus surgery tonsillectomy	anaerobic bacteria of oral cavity, aerobic gram-negative bacteria (Enterobacteriaceae and others)
eye surgery : local policy makers may identify exceptions in cataract surgery	Staphylococcus aureus, coagulase-negative staphylococci (CNS), streptococci, enteric Gram-negative bacilli	topical drops (parenteral antibiotics do not penetrate the aqueous or vitreous humour adequately) + cefazoline 100mg subconjunctivally at end of operation
neurosurgery :  craniotomy cerebral spinal fluid (CSF) shunt
election cholecystectomy (videolaparoscopy)	Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)  Enterococcus spp. Clostridium spp. Bacterioides fragilis	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline second-generation cephalosporins :  cefonicid cefotetan	i.v. (bolus or small infusion)
election cholecystectomy (abdominal route)	Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)  Enterococcus spp. Clostridium spp. Bacterioides fragilis	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline second-generation cephalosporins :  cefonicid cefotetan	i.v. (bolus or small infusion)
complicated cholecystectomy (pregressed cholecystitis/empyema)	Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)  Enterococcus spp. Clostridium spp. Bacterioides fragilis	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline second-generation cephalosporins :  cefonicid cefotetan	i.v. (bolus or small infusion)
choledocholithiasis without jaundice	Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)  Enterococcus spp. Clostridium spp. Bacterioides fragilis	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline second-generation cephalosporins :  cefonicid cefotetan	i.v. (bolus or small infusion)
obstruction jaundice	Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)  Enterococcus spp. Clostridium spp. Bacterioides fragilis	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline second-generation cephalosporins :  cefonicid cefotetan	i.v. (bolus or small infusion)
external biliary drainage	Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)  Enterococcus spp. Clostridium spp. Bacterioides fragilis	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline second-generation cephalosporins :  cefonicid cefotetan	i.v. (bolus or small infusion)
election operations on stomach, duodenum and small bowel	Staphylococcus spp. Streptococcus spp. Enterococcus spp. Escherichia coli Proteus spp. gram-positive and gram-negative anaerobes (Peptostreptococcus spp.,  Bacteroides spp.)	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline second-generation cephalosporins :  cefonicid cefotetan	i.v. (bolus or small infusion)
operations on colon (total colectomy, hemicolectomy, transversectomy, segmentary resection, etc.)	Bacteroides spp. Escherichia coli Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)	ureidopenicillins :  mezlocillin piperacillin amoxicillin/clavulanate (clavamox) second-generation cephalosporins :  cefonicid cefotetan clindamycin + gentamycin	i.v. (bolus or small infusion)
ano-rectal surgery	Staphylococcus spp. Streptococcus spp. Enterobacteriaceae (Escherichia coli, Klebsiella spp., Enterobacter spp., Proteus spp.)  anaerobes	amoxicillin/clavulanate (clavamox) first-generation cephalosporins :  cefazoline vancomycin and teicoplanin if MRSA > 50%	i.v. (bolus or small infusion)
election appendicectomy			i.v. (bolus or small infusion)
diverticulosis			i.v. (bolus or small infusion)
obstetric-gynecological surgery : antibiotic prophylaxis is recommended but local policy makers may identify exceptions in:  cesarean section hysterectomy (abdominal or vaginal) induced abortion	Enterobacteriaceae, Bacteroides spp. (including Bacterioides fragilis), Enterococcus spp.
urology :  antibiotic prophylaxis is recommended in transrectal prostate biopsy antibiotic prophylaxis is recommended but local policy makers may identify exceptions in: shock-wave lithotripsy TURP antibiotic prophylaxis is not recommended in TURBT
vascular surgery : antibiotic prophylaxis is recommended in:  lower limb amputation. vascular surgery (abdominal and lower limb)
general surgery  antibiotic prophylaxis is highly recommended in colorectal surgery. antibiotic prophylaxis is recommended but local policy makers may identify exceptions in: appendicectomy. biliary surgery (open). breast surgery. clean-contaminated procedures (extrapolated from specific clean-contaminated procedures). endoscopic gastrostomy. gastroduodenal surgery. oesophageal surgery. small bowel surgery. laparoscopic or non-laparoscopic hernia repair with mesh. antibiotic prophylaxis is not recommended in: laparoscopic or non-laparoscopic hernia surgery without mesh laparoscopic cholecystectomy
orthopaedic surgery antibiotic prophylaxis is highly recommended in: total hip replacement.* prosthetic knee joint replacement.* antibiotic prophylaxis is recommended in: closed fracture fixation. hip fracture repair. spinal surgery antibiotic prophylaxis is recommended but local policy makers may identify exceptions in insertion of prosthetic device* (extrapolated from trials of specific devices). antibiotic prophylaxis is not recommended in orthopaedic surgery without prosthetic device (elective). * Regardless of use of antibiotic cement	Staphylococcus aureus, coagulase-negative staphylococci (CNS) Less commonly enteric Gram- negative bacilli and Clostridium	cephazolin 1g iv or  cefamandole 2g iv or  cefuroxime 1.5g iv or  vancomycin 1g iv (where MRSA infections are common or patient is allergic to ß-lactam antibiotics)
major lacerations, > 4 hours and untreated	S. aureus  Streptococci  Gram-negative bacilli	Amoxycillin/clavulanic acid 1.2g iv  then 500mg orally q6-8h or  cefoxitin 1g iv q6-8h
extensive soft tissue injury, penetrating wounds or crush injuries	anaerobes	cefotetan 1g iv q12h
animal or human bites	as above plus :  Pasteurella multocida Eikenella corrodens	as above
ruptured, perforated or gangrenous viscus	as for colorectal surgery	as for colorectal surgery but treat for at least 3 days

Side effects : antibiotic-associated enterocolitis or colitis
• recognition. Because some degree of infection is inevitable, it is easy to fail to recognise the outbreak until it has reached serious proportions. Routine recordings of the temperature and pulse rate are invaluable and inspection of the wounds is undertaken. A separate register of any infection which arises in a wound should be kept in each ward. A control of infection officer (often a nursing sister) is invaluable to a hospital
• prevention : the following measures are important :
• bed spacing should be as generous as possible. A minimum of 2-4 metres is essential
• staff with minor septic lesions should not be on duty in a surgical ward
• contaminated dressings and instruments are treated as appropriate by disinfection and incineration
• sterilisation must be effective and recontamination prevented
• bed clothes should be handled gently to reduce the risk of dissemination of infection
• flies shoud be denied access and destroyed without delay if they do break bounds
• flower vases are a further source of contamination and require disinfection
• antibiotics should be used with care and not indiscriminately
• the dressing of surgical wounds requires special care. The patient should be instructed not to interfere with the dressing and to report if he requires attention for oozing of serum, pus or blood.
• nothing that is to be put into the bed should be placed on the floor - back rests, bed cradles and bedpans
• screen covers and curtains around the bed require regular laundering
• isolation : where facilities are available, patients with infections due to organisms known to give rise to epidemics, e.g. certain staphylococcal infections, are barrier nursed in a separate cubicle
• indwelling tubes and catheters are a constant jhaazard. It has been suggested that 1 in 10,000 patients admitted to hospital dies of septicaemia due to catheterisation of the urinary tract. That would account for 500 deaths in Great Britain yearly
• control. Patients with an infected wound should be, if possible, be isolated. If this is impossible barrier nursing has to be instituted at once. Infection spreads on the hands of the staff, fomites or clothes and through the air or by droplets. Hands should be washed inside the cubicle and dried outside to obviate contamination from paper cloths or paper towels stored in the cubicle. Unless gowns are used intelligently they are better not used at all. A surgeon dons a sterile gown before beginning an operation and discards it at the end. The same practice must be adopted in barrier nursing - such a practice need not add unduly to the laundry problem since the used gown usually need be only autoclaved and not laundered. Many modern gowns are disposable. It may be desirabe to close the ward to further admissions if the sepsis rate is rising or to empty the ward for cleaning and disinfection if there is a severe outbreak of infection. Investigations should include bacteriological examinations of :
• the wound
• the mouth, hands, throat and skin of the staff and careful clinical examination to discover any infective lesions in other patients
• scars may result in functional menomation, e.g. :
• lack of regrowth of skin adnexa
• valvulopathies
• liver cirrhosis
• deep venous thrombosis

Prevention :
• early patient mobilization since first postoperatory day
• lower limb lifting by 15-20° from the bed surface during and after surgery
• motory and respiratory pre- and postoperatory physiotherapy
• calcium heparin :
• 5,000 IUs 2 hours before surgery => 5,000 IUs every 8-12 hrs for 7-10 days
• 2,500-5,000 IUs immediately after surgery every 8 hrs or 3,000 IUs LMWH for 7 days
• acting DVT : 5,000 IUs i.v. bolus sodium heparin => 15-20 IUs/kg/hr i.v infusion
• preoperatory preparation
• bowel preparation
• patients undergoing general anesthesia : do not eat in the 12 hours and do not drink in the 8 hours before surgery to prevent vomiting and ingestion pneumonia
• mechanical prepation in patients suffering from constipation or undergoing supracolic gastrointestinal surgery (usually followed by paralytic ileus) and rectal surgery (associate aminoglycoside + clindamycin or metronidazole or third-generation cephalosporin) : low-fiber diet in the last 2 days, irritant laxative 24 hrs before surgery and then fluid diet => 2 1-liter bowel enemas 12 and 4 hours before surgery. In patients unable to contain enemas, PEG or 10% mannitol + 2-4 l water the evening before surgery; whole-gut irrigation using nasogastric tube and 2-4 l of NS/hr for 6 hours or until stools become clear (contraindications : water retention due to heart, renal or liver diseases, intestinal occlusions; side effects : nausea and vomiting, abdominal pain)
• i.v. antibacterials in patients with intestinal occlusions
• hygienic preparation
• whole body soap washing from the top to the bottom the evening or the morning before surgery
• trichotomy a few hours before surgery using disposable razors and depilating creams
• operatory field preparation : clorhexidine, iodopovidone, iodine tincture
• Foley's urinary catheter
• nasogastric tube
• the surgical room :
• scialitic lamps do not form shadows
• techniques and materials
• technical devices :
• lavages
• wound lavage
• peritoneal lavages
• local peritoneal lavage using 50-1000 ml NS
• complete peritoneal lavage using 5-15 l NS for diffuse peritonitis due to intestinal perforation and hemoperitoneum
• continuous peritoneal lavage using 2-10 l NS/day for diffuse peritonitis due to necrotic-hemorrhagic pancreatitis, multichambered abscesses, multibranched fistulas
• drainage for abscesses, hemorrhage, lymphorrhage, bile spreading, pus formation, necrotic debris (dirty surgery, splenectomy, polytrauma, nasogastic tube). Permanent drainage may cause infections, visceral or anastomotic compression, bending of intestinal loops, delayed wound healing, but prolonged placement is required for pancreatic and duodenobiliary fistulas
• gravity drainage
• Radon aspiration drainage (e.g. for pleural cavity)
• mechanical aspiration
• negative pressure container with 10-20 cm water column
• laparostomy for diffuse peritonitis due to necrotic-hemorrhagic pancreatitis and multiple abscesses : after 2 weeks a fibroepithelial coverage forms over exposed intestinal loops
• laparotomic zipper for diffuse peritonitis due to necrotic-hemorrhagic pancreatitis, opened every 24-48 hours for toilette after patient sedation (general anesthesia is not required)
• prostheses
• lasers
• ultrasounds
• lithotripsy
• vascular accesses and hemodialysis
• postsurgical acute renal failure occurs in 25% of election surgery (severe ARF in 0.4-7.5% of cardiosurgery (cardiopathy, arterial hypotension, and hemolysis secondary to extracorporeal circulation), 0.6% of general surgery; higher in surgery for obstructive jaundice (due to increased intestinal endotoxin resorption) and abdominal aortic aneurysm (renal ischemia during supraaortic clamping)). Mortality = 60% when requiring hemodialysis. Patients with renovascular disease (<5%) don't recover function.
• minimal access or minimally invasive surgery (MAS / MIS) : surgery done with only a small incision or no incision at all, such as through a cannula with a endoscope (laparoscope or thoracoscope, transanal, tranesophageal, and transgastric surgery) and high-definition microcamera (which allow better vision of operatory field than open surgery!), thereby reducing pain, blood loss, wound complications (hernias) hospital stay (faster recovery of respiratory and intestinal functions), infections and overall cost of an operation.

Disadvantages : loss of tactile sensation
Indications :
• laparoscopically assisted surgery (LAP)
• laparoscopic cholecystectomy (the first MAS operation practiced at Lyon, France, by Philippe Mouret in 1987) : choledochal calculi (assessed with preoperatory retrograde cholangiopancreatography) should be removed endoscopically after papillotomy before practicing the laparoscopic cholecystectomy 2 days after. Staying at hospital is reduced from 10-15 to 4-5 days : the patient may restart to work just 10 days after surgery. Complications in 4%, conversion to laparotomy < 5%; mortality = 0.1%.


• laparoscopic appendicectomy : localization of the appendix => dissection of the mesappendix => transection of appendicular artery between clips => closure of the appendiceal base with endoloops => transection of appendix => extraction of the specimen with a bag. Recommended in urgence, for retrocaceal or subhepatic appendix, and in females (for differential diagnosis with adnexial diseases)


• laparoscopic colectomy (right, transverse of left hemicolectomy, sigmectomy, or rectectomy). Indications : diverticular disease, sexile polyps, early-stage carcinomas. Colorectal end-to-end anastomosis via endorectal route with mechanical circular stapler


Laparoscopic-assisted surgery for cancer of the colon is as effective as open surgery in the short term and is likely to produce similar long-term outcomes. However, impaired short-term outcomes after laparoscopic-assisted anterior resection for cancer of the rectum do not yet justify its routine use^ref
• laparoscopic esophagoplasty (Nissen fundoplication)


• laparoscopic adrenalectomy for tumors < 10 mm. The removed adrenal is placed into a bag and extracted through a mild enlargement of one of the incisions used for trocars. Conversion to laparotomy (anterior transperitoneal or posterolateral extraperitoneal) < 5%.
• left adrenalectomy : section of splenocolic and splenodiaphragmatic ligaments


• right : lifting of right lobe of liver => isolation and section of upper adrenal vein.


• laparoscopic splenectomy for thrombocytopenia or hemolytic anemia, lymphoma staging, cystectomy; diagnosis and evaluation of traumas : isolation and dissection of lower polar vessels => ligation and dissection of splenic artery, short gastric vessels => splenocolic and splenodiaphragmatic ligaments. Large spleens are finally removed with suprapubic laparotomy.
• explorative/operational laparoscopy for doubtful gastric, pancreatic (opening of gastrocolic ligament and direct visualization) or hepatic (laparoscopic echography) cancers, peritoneal carcinosis and unexplained intestinal occlusion
• laparoscopic gastric bypass
• laparoscopic gastric bandage (lap-band)
• laparoscopic pancreatoduodenectomy
• laparoscopic total esophagectomy (+/- lymphadenectomy), diverticulectomy, extramucous myotomy, carcinoma staging
• laparoscopic total gastrectomy with enlarged lymphadenectomy, vagotomy, gastroenteroanastomosis, gastrorrhaphy
• laparoscopic enterolysis for subocclusive syndromes, ileectomy for benign neoplasms, colectomy, proctectomy, rectopexis
• laparoscopic liver tumorectomy or major hepatectomy
• laparoscopic resection of insulinoma, derivation of pseudocysts, palliative derivations for obstructive neoplastic jaundice, staging and resecability of malignant cancers, caudal pancreatectomy
• laparoscopic abdominal herniorrhaphy : Bassini's technique, Stoppa's technique
• laparoscopic live-donor nephrectomy (only for left kidney) and cystectomy : transverse suprapubic incision sectioning the muscles and fascia but not peritoneum to prevent gas escape; the trocars are inserted via "tobacco bags" and the vascularized kidney is placed into a basket before vessel resection
• laparoscopic ovarian cystectomy, diagnosis and therapy of extrauterine pregnancies, hysterectomy, endometriosis surgery
• laparoscopic spermatic vein ligation for varicocele, diagnosis and therapy of abdominal cryptorchidism, prostatectomy
• retroperitoneoscopically assisted surgery^ref
• adrenalectomy : benign adrenal tumors up to 6 cm in diameter, adrenal metastases, (i.e. renal cell cancer)
• nephrectomy
• simple nephrectomy : hydronephrosis (20%), renovascular end-stage disease (28%), chronic pyelonephritis (12%), end-stage stone disease (11%), renal dysplasia (4%), renal tuberculosis (1%), others (1%)
• nephroureterectomy : reflux nephropathy (15%), primary obstructive mega-ureter, transitional cell carcinoma of the kidney/upper ureter (Ta/T1-2)
• radical nephrectomy : renal cell cancer (T2) when transabdominal approach is impossible (ie. history of peritonitis, after dialysis) (8%)
• heminephrectomy : duplicated kidney with a hydronephrotic or dysplastic part
• renal biopsy : hemolytic-uraemic syndrome, acute glomerulonephritis or a nephrotic syndrome with increased risk of bleeding in case of or failure after ultrasound-guided percutaneous biopsy
• nephropexy : symptomatic nephroptosis with functional disorder (renal perfusion, urinary out-flow) proven on isotope nephrogram
• renal cyst marsupialization : complicated septated or suspicious cysts, large renal cysts after failure of percutaneous sclerotherapy, multiple renal cysts with deterioration of renal function, hilar cysts obstructing the ureter
• dismembered pyeloplasty : obstruction of ureteropelvic junction with hydronephrosis due to a crossing lower pole artery
• ureterolysis : obstruction of uteropelvic junction due to periureteral bands or aberrant not/crossing vessels, retroperitoneal fibrosis
• ureterocutaneostomy : mid/upper ureteral stone after failure of ESWL or ureteroscopic stone extraction
• retroperitoneal lymph node dissection : non-seminomatous testicular cancer (stage I-IIb), diagnostic "pick-up"-lymphadenectomy for retroperitoneal lymph node enlargement (i.e. malignant lymphoma, metastases)
• suspension of urinary bladder neck
• lumbar sympathectomy
• aortobifemoral bypass
• inguinal hernia alloplasty
• foreign body extraction : i.e. removal of tip of ureteral catheter lost in the retroperitoneum during ureteroscopy
• transanal endoscopic microsurgery (TEM) for extraperitoneal rectal diseases within 15 cm since anus, involving < 2/3 of circumference. Side effects : transient dysuria and fecal incontinence related to size of operating rectoscope
• resection of sexile villous adenoma
• curative resection of T1 rectal carcinoma
• palliative resection of T3 rectal carcinoma
• resection of solitary rectal ulcer
• rectopexis to treat rectal prolapse

• natural orifice translumenal endoscopic surgeries (NOTES) use a natural body opening to remove organs and tissue. The most common openings used are the mouth, anus and vagina. Since 2004, successful NOTES in humans have removed diseased gallbladders and appendixes through the mouth, and gallbladders, kidneys and appendixes through the vagina.
Devices :
• hand-assisted laparoscopic surgery (HALS) allows the laparoscopic surgeon to insert a hand into the peritoneal cavity, through a small incision, while maintaining pneumoperitoneum. This technique has been made possible through the engineering of several unique devices. By returning the hand to the peritoneal cavity, the surgeon is allowed the return of tactile sensation (palpation of internal organs and structures), atraumatic organ retraction, blunt dissection, and digital bleeding control. Proper device placement is mandatory. The principles include port-site triangulation, conversion to a convenient open incision if necessary, location away from bony prominences, and placement to minimize hand fatigue. Its use in these procedures does not appear to be detrimental to the benefits associated with a completely laparoscopic technique, and may offer advantages. It may alter the learning curve regarding advanced laparoscopic procedures for the neophyte laparoscopic surgeon, and allow them to perform operations they otherwise would not attempt. For the experienced laparoscopic surgeon, it may allow them to complete operations laparoscopically they might otherwise have to convert. In time, HALS may have a larger role in many advanced surgical procedures^ref. The appropriate position of the hand-access device and trocars for hand-assisted laparoscopic surgery depends on several factors, including the surgeon's preference, physical stature, and handedness; the patient's anatomy; and the type of procedure being performed^ref.

Ports :
• Pneumo Sleeve™ (Dexterity Surgical, Inc.)
• Intromit™ ((Applied Medical, Rancho Santa Margarita, CA, USA)
• Hand port™
• Omni port™
• GelPort™
Indications : application and advantages of HALS can be shown in several procedures
• esophagectomy
• hand-access laparoscopy (HAL) :
• laparoscopic splenectomy in cases of splenomegaly
• laparoscopic live-donor nephrectomy
• laparoscopic sigmoid colectomy for diverticular disease
• gastrectomy, hepatectomy, pancreatectomy, and bariatric surgery
• hysterectomy
• urologic (since 1997) : the most frequent minor complications were urinary retention, splenic capsular injury, and prolonged ileus
• aorto-iliac reconstructions (aortobifemoral bypass)
Limitations can be summarized to:
• fatigue
• possible impaired tactile feedback through a lengthy complex procedure and minor ergonomic restriction is due to the crowdness of the hand with the instruments.
• not wells accepted by patient and surgeons because there is already a mini laparotomy.
• cosmetically inferior than total laparoscopic surgery.
• robotic surgery
• wounds and wound repair
• anesthesia
• blood transfusions and coagulopathies
• shock
• hydroelectrolyte disorders and dysmetabolism
• postoperatory period
• immediate postoperatory period
• intermediate postoperatory period
• convalescence
• postoperatory complications
• wound complications
• respiratory complications
• alterations of gastrointestinal function
• acute renal failure
• urinary complications
• postoperatory fever
• multiple organ failure (MOF)
• adult distress respiratory syndrome (ARDS)
• fatty embolism
• cardiac complications
• postoperatory hemorrhages
• acute pancreatitis
• postoperatory parotitis
• complications of infusion therapy and monitoring
• psychic complications
• surgical infections
• wound infections (1-40%)
• respiratory infections (5%)
• urinary tract infections (5-10%)
• septicemia and biliary tract infections
• infection of catheters
• deep and soft tissue abscess
• infected decubitus ulcers
• septic thrombophlebitis
• postoperatory fever of unknown origin (5-10%) : pulmonary atelectasis and upper respiratory tract infections
• medical therapy in the surgical patient
• artificial alimentation of the surgical patient
• surgical immunobiology
• grafts
• clinical surgery : the study of surgical disease by symptomatic analysis, examination, and observation.
• operative surgery : the operative or mechanical aspect of surgery; that which deals with manual and manipulative methods or procedures.
• tele-surgery
• structural surgery : surgery devoted to the correction of morphologic abnormalities.
• tissue explants, ablations, and shapings
• ablation / ablatio : separation or detachment; extirpation; eradication; removal or destruction of a part, especially by cutting.
• catheter-induced ablation : delivery of destructive electrical energy, usually high energy or radiofrequency alternating current, via electrodes on a catheter; used in the treatment of tachyarrhythmias. It  without the use of drugs in patients with congestive heart failure and atrial fibrillation significantly improve cardiac function, symptoms, exercise capacity, and quality of life^ref. Based on the success of surgical approaches to AF, several catheter ablation strategies have been designed to produce similar effects^{ref1, ref2, ref3}. Ablation strategies limited to the RA produce marginal improvement^ref, whereas linear ablation in the LA has been more successful. The recognition that foci triggering AF often originate within the pulmonary veins has led to ablation strategies that target this zone or electrically isolate the pulmonary vein from the LA. Other sites of arrhythmogenic foci have been found in the superior vena cava, the RA and LA, and the coronary sinus. Ablation of these foci eliminates or reduces the frequency of recurrent AF in more than 60% of patients, but the risk of recurrent AF after a focal ablation procedure is still 30% to 50% over the first year and even higher when more than 1 pulmonary vein is involved. Thus, many patients continue to require antiarrhythmic drug therapy after ablative therapy of AF^ref. Potential complications of catheter ablation for AF include systemic embolism, pulmonary vein stenosis, pericardial effusion, cardiac tamponade, and phrenic nerve paralysis. Thus, although these procedures have produced promising results, they have not yet been widely applied. Atrial flutter can develop not only as a distinct arrhythmia but also during antiarrhythmic drug therapy of AF, especially with type IC agents. Catheter ablation is more effective than antiarrhythmic drugs for treatment of atrial flutter, reducing the recurrence rate from 93% to 5% when used as first-line therapy^ref. In addition, the risk of developing AF might also be lower after catheter ablation of atrial flutter than with pharmacological therapy (29% vs 60% over the first year).
• chemical ablation : destruction of an area of the myocardium by injection of small amounts of alcohol or phenol via a coronary artery; used in the treatment of tachyarrhythmias
• electrical ablation : fulguration; the term is used particularly to describe destruction of areas of myocardial tissue in the treatment of tachyarrhythmias
• photochemical ablation : laser ablation of tissue in which light absorbed by the tissue dissociates molecular bonds.
• photomechanical ablation : laser ablation of tissue in which the absorption of light energy causes stress in excess of the tissue's strength.
• photothermal ablation : laser ablation of tissue in which light is absorbed by the tissue and converted to heat, resulting in coagulation, necrosis, and vaporization
• exeresis : surgical removal or excision
• sharp dissection : dissection accomplished by incising tissues with a sharp edge.
• blunt dissection : dissection accomplished by separating tissues along natural cleavage lines, without cutting.
• excision / resection / ectomy : removal, as of an organ, by cutting
• intracapsular excision : in surgery for soft tissue sarcoma, removal of the tumor alone by direct incision of the tumor capsule; of diagnostic value only since it leaves some gross tumor intact.
• radical excision : in surgery for soft tissue sarcoma, removal of the entire anatomic compartment containing the tumor, as well as the origins and insertions of all muscles, bones, and joints contained in the compartment; frequently it involves the amputation of a limb.
• marginal excision : surgical removal of an entire lesion, including only a very small margin of surrounding tissue.
• wide excision : in surgery for neoplasms, removal of both the tumor and a margin of apparently normal surrounding tissue; the limb, breast, or other body structure that is the site of the tumor is not amputated.
• cytology : the study of cells, their origin, structure, function, and pathology.
• aspiration biopsy cytology (ABC) : the microscopic study of cells obtained from superficial or internal lesions by suction through a fine needle.
• exfoliative cytology : microscopic examination of cells desquamated from a body surface or lesion as a means of detecting malignancy to measure hormonal levels, etc. Such cells may be obtained by such procedures as aspiration, washing, smear, and scraping, and the technique may be applied to vaginal secretions, sputum, nipple secretions, urine, abdominal fluid, prostatic secretion, etc.
• biopsies : the removal and examination, usually microscopic, of tissue from the living body, performed to establish precise diagnosis.
• cytological biopsy : a procedure in which cells are obtained by various methods for pathological examinations, as by irrigation of hollow viscera
• brush biopsy : biopsy in which cells or tissue is obtained by manipulating tiny brushes against the tissue or lesion in question (e.g., through a bronchoscope) at the desired site
• excisional biopsy : biopsy of tissue removed by excision; biopsy of an entire lesion, including a significant margin of contiguous normal-appearing tissue
• cone biopsy / conization : biopsy in which an inverted cone of tissue is excised, as from the uterine cervix
• incisional biopsy : biopsy of a selected portion of a lesion and, if possible, of adjacent normal-appearing tissue.
• exploratory biopsy : exploration combined with biopsy to determine the type and extent of neoplasms, both deep and superficial
• bite biopsy : the instrumental removal of a fragment of tissue
• punch biopsy : biopsy in which tissue is obtained by a punch.
• vacuum biopsy
• shave biopsy : biopsy of a skin lesion in which the sample is excised using a cut parallel to the surface of the surrounding skin
• surface biopsy : biopsy of cells scraped from the surface of suspicious or obvious lesions, most commonly employed in examination for cancer of the cervix.
• endoscopic biopsies : removal of tissue by appropriate instruments introduced through an endoscope.
• endomyocardial biopsy (EMB) : sampling of the endomyocardial tissue with a bioptome inserted percutaneously and advanced via the femoral or right internal jugular vein to the right heart or via the femoral artery to the left heart => 3-5 biopsies


Indications :
• assess cardiac transplant rejection or anthracycline-induced cardiotoxicity
• myocarditis
• infiltrative diseases (amyloidosis, sarcoidosis, hemochromatosis)
Side effects : damage of tricuspid valve
• transbronchial lung biopsy (TBLB) : biopsy of the lung through a bronchofiberscope (or rigid bronchoscope in small children) positioned under fluoroscopic guidance
• videothoracoscopic lung biopsy (VTLB) : 3 trocars at ...
• 7^th intercostal space, on intermediate axillary line
• 5^th intercostal space, on anterior axillary line
• 5^th intercostal space, on posterior axillary line
Wedge resection with Endopath 30 or 45 3.5 mm => 2 training tubes => biopsy split.
• laparoscopic biopsy : with Menghini's or Wim-Silverman needles
• percutaneous biopsies / needle biopsy : biopsy in which tissue from deep within the body is obtained by insertion through the skin of a specifically designed needle (trucut or Vim-Silverman needle) that detaches tissue with an inner needle so that the tissue can be brought to the surface in the needle's lumen. They are usually practiced in day hospital with local anaesthesia and have high accuracy.
• aspiration biopsy : biopsy in which the tissue is obtained by the application of suction through a needle (0.6-0.9 mm in diameter) attached to a syringe
• fine-needle aspiration biopsy (FNAB) : aspiration biopsy using a fine needle; for superficial tissue such as the thyroid, breast, or prostate the needle is unguided but for deep tissue (e.g. liver) it must be guided => fine-needle aspiration cytology (FNAC)
• bone marrow aspiration (BMA) biopsy is carried out principally to permit cytological assessment of bone marrow cells. However, in some clinical circumstances other tests—for example, cytogenetic and immunophenotypic analysis—are equally important. In many patients, a trephine biopsy will be carried out as part of the same procedure. Bone marrow aspiration should be preceded by evaluation of the medical history and clinical features, examination of a blood film and assessment of results of a full blood count, other laboratory tests, and radiological investigations. It is necessary to know whether the patient is receiving, or has recently been receiving, any medication that may influence the blood count or bone marrow cytology. This includes drugs that may have an adverse effect on the bone marrow and cytokines that have been given to stimulate haematopoiesis. Even remote history may be relevant—for example, travel to an area where leishmaniasis or histoplasmosis is prevalent or previous irradiation of a site where a biopsy might otherwise have been performed. A request for bone marrow aspiration should be regarded as a request for a consultation on the patient in question and not simply as a request to carry out a technical procedure. Tests that might be required on a bone marrow aspirate :
• tests applied routinely :
• cytology on a Romanowsky stained film
• a Perls' stain for haemosiderin
• tests applied selectively :
• other cytochemical tests
• immunophenotyping
• cytogenetic analysis
• molecular genetic analysis
• culture for mycobacteria, Leishmania, Histoplasma, or other microorganisms
• deoxyuridine suppression test
• culture of colony forming units
• ultrastructural examination

Indications	need for a trephine biopsy	notes on other useful investigations
investigation of unexplained microcytic anemia : misdiagnosis of anaemia of chronic disease as iron deficiency is common and it is not infrequent for such patients to be subjected to an extensive search for a source of blood loss without a firmly based diagnosis of iron deficiency. If results of biochemical assays are equivocal it is important to perform a bone marrow aspirate to ensure an accurate diagnosis before embarking on other investigations.	only if myelodysplastic syndrome is suspected
investigation of unexplained megaloblastic anemia : it is acceptable to omit bone marrow examination if the peripheral blood features are totally typical and if assays of vitamin B12 and folic acid are suggestive of a deficiency state. Otherwise, bone marrow aspiration is still indicated. If the diagnosis does not appear straightforward, or if the patient requires urgent treatment and haematinic assays are not available, bone marrow aspiration is indicated.	only if myelodysplastic syndrome is suspected	deoxyuridine suppression test may be useful but is mainly a research technique
investigation of unexplained anaemia	usually	cytogenetic analysis if MDS is suspected; ultrastructural examination if congenital dyserythropoietic anaemia is suspected
investigation of unexplained thrombocytopenia	only if myelodysplastic syndrome is suspected
investigation of pancytopenia (including suspected aplastic anaemia)	yes	cytogenetic analysis if MDS is suspected; appropriate culture if mycobacterial infection or leishmaniasis is suspected; bone marrow is a useful source of DNA if investigation for Pearson's syndrome is required; cytogenetic analysis if a haemophagocytic syndrome is suspected (because EBV-related haemophagocytic syndrome may be associated with a clonal proliferation of neoplastic T cells)
investigation of a leucoerythroblastic blood film and suspected bone marrow infiltration	yes	cytogenetic analysis if a haematological neoplasm is suspected; if an abnormal infiltrate is found, immunophenotyping and cytogenetic analysis may be useful; cytogenetic analysis is indicated if a small cell tumour of childhood is suspected because the demonstration of certain specific cytogenetic abnormalities can confirm the diagnosis
investigation of suspected acute leukaemia : although it is often possible to establish a diagnosis of acute leukaemia from peripheral blood examination, bone marrow aspiration should nevertheless be carried out. This is both because the likelihood of successful cytogenetic analysis is higher if bone marrow cells are used and because a baseline is needed for comparison with bone marrow aspirates performed during treatment. In addition, bone marrow aspiration permits the assessment of trilineage dysplasia, which may be of prognostic relevance.	no (unless there is difficulty obtaining a good aspirate)	cytogenetic and possibly molecular genetic analysis; immunophenotypic analysis unless cells are clearly myeloid
assessment of remission status after treatment of acute leukaemia	no (unless there is difficulty obtaining a good aspirate)	follow up cytogenetic analysis is only occasionally useful; molecular genetic analysis may be indicated for assessment of minimal residual disease
investigation of suspected myelodysplastic syndromes/ myeloproliferative disorders	yes	cytogenetic analysis; investigation of colony forming units if juvenile myelomonocytic leukaemia is suspected
investigation of suspected chronic myeloid leukaemia : usually offers little diagnostically useful information beyond that which can be gleaned from a careful examination of the peripheral blood. However, as for the acute leukaemias, cytogenetic analysis is more often successful when performed on the bone marrow and aspiration is therefore indicated for this purpose	no (unless there is difficulty obtaining a good aspirate or if the accelerated phase of the disease or blast transformation is suspected)	cytogenetic analysis; molecular genetic analysis is not indicated because it can be performed, when necessary, on peripheral blood cells
follow up of chronic myeloid leukaemia	no	cytogenetic analysis
investigation of suspected myeloproliferative disorders (polycythaemia rubra vera, essential thrombocythaemia, idiopathic myelofibrosis, or systemic mastocytosis)	yes	cytogenetic analysis; investigation of colony forming units (erythropoietin independent burst forming units) may be useful but in most centres is not a routine diagnostic test
investigation of chronic lymphocytic leukaemia : the diagnosis of chronic lymphocytic leukaemia can usually be made without difficulty from the peripheral blood features and the immunophenotype. A bone marrow aspirate is therefore not essential in patients with early stage disease, particularly in elderly patients in whom treatment may never become necessary. Bone marrow assessment is indicated before treatment is undertaken	yes because the bone marrow aspirate gives very little information beyond that already available from examination of the blood, while BMTB permits an accurate assessment of the extent of infiltration and gives information of prognostic importance. During follow up of intensive treatment of CLL there is little point in performing a bone marrow aspirate alone because there may be residual disease detectable only by trephine biopsy.	immunophenotyping is not indicated because it can be performed easily on the peripheral blood
investigation of suspected non-Hodgkin's lymphoma : diagnosis of non-Hodgkin's lymphoma is usually based on a lymph node biopsy. However, in patients with bone marrow involvement, diagnosis can be reliably based on cytology, immunophenotyping, and the pattern of bone marrow infiltration. When there are circulating lymphoma cells, immunophenotyping can be performed on the peripheral blood and the bone marrow aspirate is of little importance. The trephine biopsy is much more important because it permits an assessment of the pattern and extent of infiltration, which is of both diagnostic and prognostic relevance, and may demonstrate lymphoma when no abnormal cells have been detected in the blood or the bone marrow aspirate. However, if circulating lymphoma cells are not present, the detailed immunophenotyping that is possible on cells in a bone marrow aspirate can help in both diagnosis and classification of NHL	yes	if an abnormal infiltrate is present, immunophenotyping, molecular analysis and cytogenetic analysis may be needed
diagnosis and follow up of hairy cell leukaemia	yes	immunophenotyping, unless there are sufficient circulating cells for it to be performed on peripheral blood cells; tartrate resistant acid phosphatase stain if detailed immunophenotyping is not available
staging of low grade non-Hodgkin's lymphoma (if the results of investigation will alter management)	yes. A bone marrow biopsy performed in patients with low grade lymphoma sometimes shows unexpected high grade transformation, which necessitates a different therapeutic approach.	immunophenotyping, unless there are sufficient circulating cells for this to be done on blood cells; cytogenetic and molecular genetic analyses are sometimes useful if the specific type of NHL has not already been determined
staging of high grade non-Hodgkin's lymphoma (in those cases where results of the investigation will alter management)	yes
investigation of  multiple myeloma (indicated)  monoclonal gammopathy of undetermined significance (MGUS) (controversial). If such patients are referred to a haematologist then a bone marrow aspirate is often performed. However, it should be remembered that at least 1% of patients over the age of 60 years have a paraprotein and over the age of 70 years the figure rises to 3%. Furthermore, investigation of serum immunoglobulins is often performed without a clear clinical indication. It seems reasonable not to perform a bone marrow examination if a low concentration paraprotein has been detected almost incidentally in a patient who does not have anaemia, bone pain, hypercalcaemia, or other relevant clinical features.  A crush preparation of bone marrow fragments is useful	generally indicated. Because infiltration is often focal, it is sometimes essential for a diagnosis. In other patients it provides a baseline for comparison with follow up biopsies	cytogenetic analysis may be useful because demonstration of poor prognosis abnormalities may influence management; immunophenotyping is only needed if cytology of the aspirate is not diagnostic and if it is not certain whether or not a monoclonal plasma cell population is present
investigations of suspected storage disease	not essential
investigation of fever of unknown origin (FUO)	yes	cultures for mycobacteria and also, if there is a possibility of previous exposure, for Leishmania and Histoplasma
in suspected chromosomal disorders in neonates when rapid confirmation is required	no	cytogenetic analysis (may produce results in 1 day cf. several days if cultured peripheral blood lymphocytes are used)
confirmation of normal bone marrow if bone marrow is being aspirated for allogeneic HSCT	no
autoimmune thrombocytopenic purpura (AITP) : some controversy surrounds the role of bone marrow aspiration in suspected AITP. In children, the American Society of Haematology (ASH) guidelines suggest that bone marrow aspiration is not usually neededref. The guidelines of the British Paediatric Haematology Group recommend bone marrow examination for children whose disease does not remit within 2-3 weeks or if treatment, especially with corticosteroids, is plannedref. The consensus has swung against BMAB provided the history and the clinical picture is entirely typical of acute onset ITP and the peripheral blood is entirely normal apart from profound and isolated thrombocytopenia. However, the threshold for marrow examination should be low if there is the slightest clinical doubtref.  in adults with acute onset of thrombocytopenia, treatment is usually indicated and in British haematological practice a pretreatment bone marrow aspiration is usually thought to be indicated. If AITP appears very likely, trephine biopsy is not needed in adults with moderately severe chronic thrombocytopenia, investigation is indicated to establish a diagnosis, even if immediate treatment does not appear to be indicated. If autoimmune disease appears very likely, only an aspirate is required but, if a myelodysplastic syndrome is suspected, a trephine biopsy is also needed. American practice appears to differ somewhat from that in the UK, with the ASH guidelines suggesting bone marrow aspiration only in patients above the age of 60 yearsref.

Site of aspiration : the need for a trephine biopsy is an indication for selecting the iliac crest, usually the posterior superior iliac spine, as the site for aspiration. The anterior iliac crest is also satisfactory, at least in thin patients. If only an aspirate is needed either the ilium or the first part of the body of the sternum can be used. The iliac crest is safer but it is often preferable to use the sternum in very obese or immobile patients. Sternal aspiration may also be necessary if the pelvis has been irradiated. Sternal aspiration is safe if proper procedures are followed. In children, the posterior superior iliac spine is usually a suitable site for aspiration. Even in babies this site is often suitable and it is rarely necessary to use the tibia. If clinically indicated, bone marrow aspiration can also be carried out at other sites—for example, at sites of focal bone marrow disease identified by scanning procedures or radiology.
Planning the bone marrow aspirate : although it may seem self evident, it is necessary to plan a bone marrow aspiration to ensure not only that the procedure is safe and causes minimal discomfort to the patient but also that all appropriate specimens are taken into the correct anticoagulant and despatched to the correct laboratory. The appropriate supplementary tests may be better determined after the bone marrow aspirate has been examined. Therefore, it is often useful to take a 10 ml sample into preservative free heparin and stain and examine a single film rapidly before deciding whether supplementary investigations are indicated and, if so, which are most likely to be informative.
Choice of needle : disposable needles are preferable. All of the standard needles are satisfactory for aspiration biopsy of the iliac crest. It is acceptable to remove the guard, if necessary, to provide a greater length of needle in obese patients. For sternal aspiration the needle selected should have a guard that screws along the needle—for example, a Klima needle—because the guard cannot slip during the procedure. A needle with a guard secured by a side screw—for example a Salah needle—is less satisfactory because the guard can slip, allowing the needle to penetrate further than was intended. Occasionally, in a very obese patient, it is necessary to use a needle-cannula for anesthesia and a trephine biopsy needle, which is generally longer than an aspiration needle, to obtain an aspirate from the iliac crest.
Operator and patient safety : the patient should be questioned with regard to allergy to latex, local anaesthetic, or any antiseptics or sedatives that might be used. Sterile gloves should be worn and an aseptic technique must be used. Gloves are for the protection of the operator as well as the patient. Because of the high incidence of allergy in individuals exposed to latex, the gloves selected should ideally be non-powdered and non-latex. If latex gloves are used they should have a low amount of extractable latex proteins; there is evidence that corn starch glove powder aerosolises latex protein, leading to inhalation of potential allergens by the operator and others. If either the operator or the patient is allergic to latex, gloves chosen should be vinyl, neoprene, or nitrile. On safety grounds, it is preferable to use disposable needles. This not only eliminates the risk of transmission of infection to the current or future patients but also avoids the necessity for cleaning non-disposable needles, a procedure that may be hazardous for staff.
• when aspirating from the sternum, it is of vital importance to aspirate only from the first part of the body of the sternum (or from the manubrium) and to judge the depth carefully. The needle that is used for infiltrating with local anaesthetic can be used to measure the depth of the periosteum, the guard then being set so that the needle will penetrate only 5–6 mm beyond the depth of the periosteum. Particular care must be exercised in patients with suspected multiple myeloma and in elderly patients who may have osteoporosis; inadvertent penetration through the sternum is more likely in these patients if the needle guard is not set correctly or if a needle with an insecure guard is used
• when aspirating from the posterior superior iliac spine, the guard can safely be set so that the needle can penetrate up to 1 cm beyond the surface of the bone.
Bone marrow aspiration and, in particular, trephine biopsies should not be carried out single handedly. A trained assistant can prepare slides. Alternatively, the operator can prepare slides while the assistant applies pressure to the wound to ensure adequate haemostasis. The assistant should, of course, wear gloves for his/her protection. Bone marrow aspiration is sometimes required in patients with thrombocytopenia or hypocoagulability. Excessive bruising or bleeding is very unlikely in patients with thrombocytopenia if 5 minutes of firm pressure is applied at the end of the procedure. However, as a precaution and assuming that the procedure was performed on the posterior iliac crest, the patient should lie on his/her back for a further 10–15 minutes to apply more prolonged pressure. Bruising is more likely if a patient has a coagulation defect or is anticoagulated. When possible, any clotting defect should be corrected before aspiration is performed.
Patient comfort : an appropriate explanation of the procedure is essential for patient confidence and for very anxious patients it is better to avoid the sternum. Adequate local anaesthesia is important to minimise pain. The skin, subcutaneous tissues, and periosteum should be infiltrated, with particular attention being paid to the periosteum. It is important to wait until the local anaesthetic has had time to take effect and to test for adequacy of anaesthesia before proceeding. The patient must be warned of the possibility of suction pain before it occurs and be reassured that it will be brief. If vacuum suction is distressing, slowing the rate of aspiration using a syringe is indicated. No sedation is necessary in adults who are having only an aspirate performed unless they are unusually anxious. In children, particularly those requiring repeated bone marrow aspirations and other procedures during the treatment of acute leukaemia, it is preferable to perform the procedure under a general anaesthetic.
Patient consent : when bone marrow aspiration is to be performed under a general anaesthetic or heavy sedation it is essential that an explanation is given in advance and that a consent form is signed. For other patients, local practice should be followed with regard to signing a consent form. Most hospitals consider that oral consent after an appropriate explanation is sufficient for conscious patients. Seeking written consent may merely increase the patient's apprehension.
Technical considerations :
• when aspirating from the sternum, the needle should be inserted slightly to one side of the midline because bone marrow is less cellular in the midline. The needle should be inserted at right angles to the surface of the bone
• in carrying out a biopsy from the posterior superior iliac spine, the needle should be inserted into the bone in the direction of the anterior superior iliac spine, to avoid penetration of the sacroiliac joint. The patient can be in the lateral decubitus position or, if thin, can be prone
• the anterior iliac crest is technically less satisfactory but can be used if there is some reason not to use the posterior iliac crest. If the patient is thin enough for the ilium to be grasped between the thumb and finger of the left hand a direct approach through the thick cortex into the anterior superior iliac spine is possible. Otherwise a lateral approach just below and behind the anterior superior iliac spine can be used. For either approach the patient should be supine.
The minimum amount of bone marrow needed for the tests indicated should be aspirated because the greater the volume of marrow aspirated the more dilution by peripheral blood occurs. If a large volume of bone marrow is needed—for example, for cytogenetic analysis or immunophenotyping—it is useful to aspirate about 0.25 ml first, this being used for spreading films, and then to use a second syringe to obtain a further sample. Ideally, films should be spread immediately without any anticoagulant being added. However, if there has been any difficulty in aspiration and it is thought that the specimen might clot rapidly, part of the aspirate should be put into anticoagulant. Glass slides with a frosted end for labelling should be used. The spreader should be narrower than the width of the glass slide to facilitate examination of the edges of the bone marrow film. A small drop of marrow should be placed about 1 cm from the end of the slide and spreading should be towards the frosted end. This ensures that it will be possible to examine the thinnest part of the film, where cytological details are optimal, while the slide is firmly positioned on the stage. Spreading away from the frosted end towards the end of the slide may mean that it is very difficult to examine an important part of the film by high power because the slide is not stable on the microscope stage. A plastic pipette should be available in case the first films spread suggest that the marrow is very dilute and it is necessary to concentrate fragments. Various techniques can be used. A large drop of bone marrow can be put on one end of a slide and the liquid part of the marrow can be aspirated from one edge of the drop, using the pipette, before the residual more cellular marrow is spread. Alternatively, a large drop of bone marrow can be put in the centre of a slide and the liquid part can be poured off on to a gauze square or can be aspirated with the pipette. Any fragments present are then visible and can be picked up with the edge of the spreader and spread on another slide. In some circumstances it can be useful to make a crush preparation. A drop of bone marrow containing fragments is placed in the middle of a slide and a second slide is then placed on top of the first. The slides are dragged away from each other, in the direction of the long axis of the slide, so that any fragments present are crushed. This technique is particularly important in suspected multiple myeloma, when neoplastic cells are sometimes present in larger numbers in fragments than in trails. It would probably also be a useful technique in systemic mastocytosis, in which mast cells often remain within fragments. If no bone marrow has been aspirated into the syringe there may nevertheless be a small drop in the needle; attempts to express this should be made by reinserting the trocar into the aspiration needle. When bone marrow aspiration is being performed for suspected acute promyelocytic leukaemia, the aspiration and spreading should be done as rapidly as possible to avoid clotting of the sample. It is particularly useful to have an assistant under these circumstances. The first 0.1–0.2 ml aspirated should be spread immediately, without prior manipulation, while an assistant applies a second syringe and aspirates further bone marrow for cytogenetic analysis.
Stained bone marrow films showing a film of appropriate length, spread towards the frosted end where the label is applied (patient 1), and a film that is too long and has been spread, incorrectly, away from the frosted end where the label is applied (patient 2).

If it is necessary to anticoagulate bone marrow before spreading films, a salt of EDTA (for example, K₂EDTA) should be used, with the amount of EDTA being appropriate for the volume of bone marrow. This is most easily achieved using a small bottle intended for paediatric blood samples. Films should be spread without delay to avoid storage artefact. Anticoagulation for supplementary tests :
• cytogenetic analysis : preservative free heparin
• immunophenotyping : either heparin (not necessarily preservative free) or EDTA
• molecular genetic analysis : EDTA is satisfactory, although preservation of DNA may be better in heparin if there is any delay in transport of the specimen
• ultrastructural examination : a drop of bone marrow should be put directly into glutaraldehyde
The slides should be labelled immediately the films are made, using a pencil to write on the frosted end of the slide. Minimum labelling requirements at this stage are the patient's surname and the date. Any residual bone marrow aspirate can be left in the syringe until it clots and can then be teased out into formal saline and submitted for histological examination. Alternatively, the bone marrow can be expelled immediately into formalin, which disperses the particles; they can then be collected as a cytoblock or into a filter. Either of these techniques increases the likelihood of detecting focal lesions and the presence of abnormal cells trapped within fragments; the absence of clotted blood with the second technique gives a better sample for cutting and provides sections that are more convenient to examine. If a trephine biopsy is being carried out at the same time as the aspirate these procedures are redundant. If it is not clear whether or not supplementary investigations are indicated, part of the bone marrow should be anticoagulated with preservative free heparin. A single bone marrow film should be examined and, depending on the findings, the specimen can then be despatched for whatever investigations appear relevant. For example, if an aspirate were being done because of a leucoerythroblastic anaemia and the bone marrow film showed carcinoma cells cytogenetic analysis would not be indicated whereas, if the film suggested a possible haematological neoplasm, cytogenetic analysis should be done. If preservative free heparin is used as the anticoagulant the marrow specimen will be suitable for any of the usual supplementary tests.
Processing and staining of bone marrow films : bone marrow slides should be thoroughly dry before they are fixed or artefactual changes occur. For example, the nuclear contents appear to leak into the cytoplasm of erythroblasts, an appearance that can be misinterpreted as dyserythropoiesis. When dry, the films should be thoroughly fixed in methanol or whichever fixative is indicated for specific cytochemical stains. The methanol should be fresh so that there is no artefact introduced by water absorbed into the methanol. Bone marrow films should be stained with a Romanowsky stain, such as May-Grünwald-Giemsa or Wright-Giemsa. They can be stained in an automated staining machine or manually. If urgent examination is needed only one film should be fixed and stained because drying may be inadequate. The remainder of the slides are processed when thoroughly dry. A film with at least one fragment, preferably more, should be used for a Perls' stain (for assessment of iron stores) on all initial bone marrow biopsies. This stain can generally be omitted from subsequent procedures. All iron stains should be performed together with a control slide, containing fragments, from a patient known to have iron in bone marrow fragments. Once stained, a cover slip should be applied and the slide should be labelled with the patient's name and the date (not omitting the year). Usually a laboratory number is also allocated and included on the label.
Assessing and reporting bone marrow films : unless a very recent blood count and film is available a venous blood sample should be obtained at the same time as the bone marrow aspirate. A blood film should already have been examined carefully in the prebiopsy assessment of the patient but should be examined again as part of the assessment of the bone marrow aspirate. A reticulocyte count, performed on the day of the bone marrow aspiration, can be useful—particularly for determining whether erythroid hyperplasia is associated with effective or ineffective erythropoiesis. The films should first be examined under low power (x10 objective) to assess the number of fragments, the cellularity, and the number of megakaryocytes, and also to detect any low incidence abnormal cells such as carcinoma cells. The films should then be examined in detail using a x40 or x50 objective. There should be a systematic assessment of the cellularity and contents of fragments, megakaryocyte number, and morphology and cytological features of other lineages. Fine cytological details should be assessed using an oil immersion x100 objective. A differential count should be performed in the trails behind several fragments because this will be the part of the film minimally diluted by peripheral blood. At a minimum, several hundred cells should be counted, with the granulocyte and erythroid series, lymphocytes, and plasma cells being enumerated and a myeloid to erythroid cell ratio being calculated. Depending on the indication for the bone marrow aspiration, this may be all that is required. For example, a more detailed differential count would not be required if the bone marrow features were those of iron deficiency or megaloblastic anaemia. However, if the features were those of acute leukaemia or a myelodysplastic syndrome a 500 cell differential count should be performed, and all cell types should be enumerated. Similarly, if the features were those of multiple myeloma with 80% of myeloma cells being present, a detailed differential count would not be necessary. However, if myeloma or MGUS was suspected but the number of plasma cells was only moderately increased, 500 cells should be counted and the count should include several different bone marrow films. A focal increase in cells of one particular lineage should be noted. Both blast cells and myeloma cells are sometimes irregularly distributed so that a differential count should be performed in the area where abnormal cells are most numerous. The report might then read—for example, "overall plasma cells are 10% of bone marrow cells but in the trails behind several fragments they comprise 30–40% of cells". The quantitative and qualitative assessment of cells in Romanowsky stained films should be followed by assessment of the iron stain and any cytochemical stains. If stainable iron is absent from fragments but there are only small numbers of fragments available for assessment this should be noted. The report might read—for example, "no storage iron detected but only one fragment available for assessment". If a patient has had previous bone marrow aspirations performed, comparison should be made with previous films to assess disease progression or treatment response. The report of the bone marrow films should include the clinical details, the major features of the blood count, the results of blood film examination, and the bone marrow findings. It is useful to include the white cell count, haemoglobin concentration, platelet count, mean cell volume, and reticulocyte count as a routine, but in selected patients other important blood count abnormalities should be recorded. The report should then include details of the aspiration procedure, specifically the site of aspiration, whether aspiration was easy or difficult, and whether or not bone texture was normal. The report on the bone marrow films should differentiate factual statements from opinion. The body of the report should include an assessment of cellularity and a systematic description of each lineage. The myeloid to erythroid cell ratio and the salient features of the differential count should be given. The report should include a list of other investigations that have been performed—for example, "trephine biopsy and immunophenotyping to follow", so that clinical staff are aware of any investigations that are still pending. Finally, the report should have a summary or conclusion in which it is appropriate to express an opinion and, if necessary suggest further tests. If it is possible to make a definite diagnosis this should be done. Varying levels of certainty might be expressed as follows: (1) "the findings are those of multiple myeloma" or "the diagnosis of multiple myeloma is confirmed"; (2) "the bone marrow features are compatible with multiple myeloma but are insufficient in themselves to establish the diagnosis" or "the bone marrow findings support a diagnosis or multiple myeloma but should be assessed in the light of clinical, radiological, and other laboratory features"; (3) "the bone marrow aspirate does not support a diagnosis of multiple myeloma but results of the trephine biopsy are still outstanding" or "the bone marrow aspirate shows no features suggestive of multiple myeloma". If a bone marrow aspirate fails or yields only peripheral blood it should nevertheless be reported so that a record of the attempt exists in the laboratory and in the patient records. The site of attempted aspiration and the bone texture should be reported. Stained bone marrow slides should be stored as long as is economically feasible, preferably for 20 or 30 years. A peripheral blood film should always be stored with the bone marrow slides. It is also useful to store unstained, unfixed slides for a shorter period in case further investigation is subsequently indicated, or more stained slides are required—for example, if the patient is transferred to another hospital or is entered in a clinical trial. Unstained slides also provide a source of positive control slides for iron stains. Unfixed slides constitute a biological hazard and, once thoroughly dry, are best stored in sealed plastic containers.
Instead of standard 12-14 G needles (€ 18), some use narrow sterile and pyrogen-free disposable spinal needles sterilized by ethylene oxide (Yale 18Gx31/2”). When using this needle, local anesthetia is not usually required because penetration of the skin is not painful. The only slight pain which may be felt is almost exclusively due to the aspiration of the bone marrow. The quantity of bone marrow blood which can be obtained is comparable to that obtained using standard needles. The collection of 10 mL or more of marrow may be easily obtained for cryopreservation of the cells. The reasons for failure of the technique are the same as those found using standard needles and are related to the type of blood disease (myelofibrosis, severe aplastic anemia, osteomyelosclerosis, and treatment with a-interferon). In these cases there is no need to use standard larger needles (14-16G) and bone marrow trephine biopsy must be carried out using Jamshidi needles^ref
• bone marrow trephine biopsy (BMTB) is an uncomfortable procedure for the patient and carries some risks; therefore, it should be performed only when there is a clear clinical indication. At least 5 patients have been reported who suffered considerable haemorrhage, sometimes with long term morbidity, as a result of trephine biopsy^{ref1, ref2}. In addition, at least 2 haemorrhagic deaths resulting from this procedure have not been published. An aspiration biopsy^ref should always be carried out as part of the same procedure. Clinical details and the results of relevant laboratory tests including the blood count and blood film features must be known before a bone marrow biopsy is performed.

Indications :
• definite indications :
• investigation of suspected Hodgkin's disease and non-Hodgkin's lymphoma
• staging of non-Hodgkin's lymphoma
• diagnosis and follow up of hairy cell leukaemia
• evaluation and follow up of chronic lymphocytic leukaemia
• diagnosis of suspected metastatic carcinoma
• diagnosis, staging, and follow up of small cell tumours of childhood
• investigation of suspected myeloproliferative disorders (polycythaemia rubra vera, essential thrombocythaemia, idiopathic myelofibrosis, and systemic mastocytosis)
• diagnosis of aplastic anaemia, hypoplastic myelodysplastic syndromes, and hypoplastic acute myeloid leukaemia
• investigation of an unexplained leucoerythroblastic blood film
• investigation of a fever of unknown origin (FUO)^ref
• investigation of suspected bone disease
• evaluation of any patient in whom an adequate bone marrow aspirate cannot be obtained
• investigation of patients in whom multiple myeloma is suspected and investigation of selected patients with serum paraproteins without other evidence of multiple myeloma
• possible indications :
• investigation of suspected acute myeloid leukaemia
• investigation of suspected myelodysplastic syndromes
• staging of Hodgkin's disease
• evaluation of chronic myeloid (granulocytic) leukaemia
• investigation of suspected primary amyloidosis
Indications can be summarised as follows:
• inadequate or failed aspirate
• need for accurate assessment of cellularity, whether increased or decreased.
• suspected focal lesion (for example, suspected granulomatous disease or lymphoma).
• suspected bone marrow fibrosis
• need to study bone marrow architecture
• need to study bone structure or bone marrow blood vessels.
In general, patients who have a hypocellular bone marrow or bone marrow fibrosis are likely to need a trephine biopsy for adequate assessment. In such patients, an aspirate will probably be inadequate or even impossible. Similarly, only a trephine biopsy shows the architecture of the bone marrow and permits the detection of an abnormal distribution of cells, bone marrow granulomas, and focal lymphoid infiltrates. There is also a greater likelihood of detection of infiltration by non-haemopoietic neoplasms. Unexplained pancytopenia and an unexplained leucoerythroblastic blood film are indications for a trephine biopsy because they are likely to indicate bone marrow infiltration or fibrosis.
• lymphoproliferative disorders : some controversy surrounds the role of the trephine biopsy in lymphoproliferative disorders.
• not all patients with chronic lymphocytic leukaemia require bone marrow examination because the disease can usually be diagnosed without difficulty from peripheral blood cytology and immunophenotyping. Patients with early stage disease do not require active treatment and bone marrow biopsy is not essential for management. However, a bone marrow trephine biopsy is indicated in patients in whom treatment is necessary, either those with more advanced disease or younger patients in whom intensive treatment is planned. A trephine biopsy is essential for follow up of intensive treatment because it may show residual focal disease when a bone marrow aspirate is normal. In fact, a bone marrow aspirate is of little value in chronic lymphocytic leukaemia; it is peripheral blood examination and trephine biopsy that are important.
• Hodgkin's disease (HD) is sometimes diagnosed from trephine biopsy histology. The biopsy will usually have been done for the investigation of pancytopenia or of systemic symptoms such as fever. Diagnosis by bone marrow biopsy is relatively frequent in HIV⁺ patients, who often present with stage IVB disease. Trephine biopsy is not mandatory in the staging of HD diagnosed at another site^ref. In one series, management was altered by the results of biopsy in < 1% of patients^ref. Management of the patient will not be altered if it is already known that the patient has stage III or IV disease or if, for any other reason, treatment by chemotherapy is intended. Patients with clinical stage IA disease very rarely have bone marrow infiltration and it has been considered justifiable to avoid trephine biopsy in such patients. Only the rare patients with stage IB disease and some patients with stage II disease require bone marrow examination because the results of the investigation might determine the choice of treatment. If bone marrow examination is required in HD, a trephine biopsy is essential because, even when the marrow is involved, it is rare for neoplastic cells to be detected in an aspirate.
• a trephine biopsy may permit a diagnosis of non-Hodgkin's lymphoma, particularly low grade lymphoma in which the marrow is often infiltrated. It is also of some use in classification if a lymph node biopsy is not available because paratrabecular infiltration is much more common in follicular lymphoma than in other categories. Although a lymph node biopsy is preferred for precise diagnosis, consideration of the immunophenotype and the pattern of bone marrow infiltration can permit a provisional categorisation, and the addition of cytogenetic or molecular genetic analysis may mean that a precise diagnosis can be made without a lymph node biopsy. Biopsy can also be required for staging purposes. Because of increased reticulin deposition in infiltrated areas, the rate of detection may be higher with a trephine biopsy than with an aspirate. However, the 2 investigations should be regarded as complementary because either may reveal infiltration when the alternative procedure fails to do so^ref. A trephine biopsy performed for staging sometimes shows discordant histological subtype or discordant grade. When high grade disease is found in a bone marrow biopsy specimen from a patient with low grade disease at another site there are clear therapeutic implications.
• acute lymphoblastic leukaemia : a trephine biopsy is unnecessary for the diagnosis as long as a cellular aspirate is obtained.
• multiple myeloma and other plasma cell neoplasms : bone marrow aspiration and trephine biopsy should be regarded as complementary investigations in suspected multiple myeloma. A trephine biopsy is essential for diagnosis in some patients. In others in whom an aspirate permits a definitive diagnosis the trephine biopsy is important as a baseline for comparison with repeat biopsies during follow up. Not all patients with a low concentration of a paraprotein require bone marrow examination, particularly elderly patients in whom the abnormality has been detected almost incidentally. However, if investigation is thought to be indicated this should include a trephine biopsy because this may demonstrate much more extensive infiltration than is suspected from the bone marrow aspirate. Immunocytochemistry and immunohistochemistry can be useful in establishing the presence of a relatively small plasma cell clone but if the patient is known to have a paraprotein these investigations are not essential. A trephine biopsy is much more useful than an aspirate in assessing suspected light chain associated amyloidosis because the biopsy specimen is far more likely than the aspirate to show amyloid deposition.
• metastatic tumour : a BMTB is essential if bone marrow examination is being carried out for suspected metastatic disease because the rate of detection of tumour cells is higher than with an aspirate^{ref1, ref2, ref3, ref4}. Nevertheless, trephine biopsy and bone marrow aspiration should be regarded as complementary investigations because either may show tumour cells when the other procedure fails to do so^{ref1, ref2, ref3}. A trephine biopsy has the advantage that, because of the possibility of assessing tissue structure and applying histochemical stains, it may be possible to predict the tissue of origin of metastatic tumour—for example, breast or prostate gland—and this may be of relevance to the choice of treatment. Whether bone marrow examination is essential for staging patients with malignant disease depends on what treatment is intended, on whether bone marrow infiltration is likely, and on whether any bone marrow infiltration detected will alter the management of the patient. For example, in small cell carcinoma of the lung it has been concluded that bone marrow examination is not necessary^ref or is rarely necessary^ref. The bone marrow is the sole site of detected metastatic disease in < 2% of patients and those with bone marrow infiltration have a median survival only a little worse than that of other patients with extensive disease^ref. It has been estimated that if an appropriate algorithm is followed and investigation is stopped as soon as the first site of metastatic disease is identified unnecessary investigation can be avoided and a third of initial evaluation costs can be saved^ref. BMTB is essential in the initial staging of certain paediatric tumours, such as neuroblastoma, rhabdomyosarcoma, PNET, and Ewing's sarcoma. The detection of bone marrow infiltration in the initial staging bone marrow biopsy means that trephine biopsy is also required during follow up.
• granulomatous diseases : a trephine biopsy is always indicated if bone marrow examination is being performed for suspected granulomatous diseases such as sarcoidosis, tuberculosis, cryptococcosis, or histoplasmosis. The detection rate is much higher because the increased reticulin deposition associated with granuloma formation often means that there is a dry tap or only relatively normal bone marrow is aspirated^{ref1, ref2}.
• acquired immune deficiency syndrome (AIDS) : a bone marrow trephine biopsy is often indicated in patients with AIDS. Specific indications in this context include pancytopenia, fever, and lymphadenopathy. A bone marrow aspirate is much less useful in such patients and, if bone marrow examination is thought to be indicated, it should always include a trephine biopsy. The biopsy may show granulomas or lymphomatous infiltration when the aspirate is uninformative.
Site and technique of biopsy : a trephine biopsy is usually most easily carried out on the posterior superior iliac spine, with the patient in the left or right lateral position and with the knees drawn up. An alternative site is the ilium, just below the anterior superior iliac spine, with the patient supine and the approach being perpendicular to the ilium.
• sternal biopsy or puncture : biopsy of bone marrow of the sternum; done by puncture or trephining. It was only with the introduction of allogeneic bone marrow transplantation in 1970s, and the need to aspirate large quantities of bone marrow from donors, that aspiration from the iliac crest and the posterior iliac spine began to be performed.
• posterior iliac crest and spine
It is preferable to use disposable needles to avoid the risks associated with cleaning reusable needles. Various needle designs are satisfactory including Jamshidi needle and Islam needle. Appropriate sterile gloves^ref should be worn and an aseptic technique must be used. A trephine biopsy and aspiration biopsy can be carried out through the same skin incision but with the bone being entered at 2 different points, about 1 cm apart. The aspiration is usually performed first but, if a very large aspirate is taken, this may lead to disruption of the tissues that are subsequently included in the trephine biopsy specimen. However, release of thromboplastic substances is likely to mean that the probability of obtaining an adequate aspirate is less if aspiration is performed after, rather than before, a trephine biopsy. It is also easier to perform the least painful procedure first. On balance, it seems preferable to perform the aspirate first, particularly in those cases where it is likely to be crucial in diagnosis. Local anaesthesia must be adequate with particular attention being paid to infiltrating an adequate area of the periosteum (mepivacaine + adrenaline (only mepivacaine in patients suffering from ischemic heart diseases) 2.5 ml for peristeoal anesthesia; mepivacaine + adrenaline 2.5 ml + sodium bicarbonate 1.5 ml + NS 1.5 ml for subcutaneous anesthesia). The adequacy of anaesthesia must be confirmed before proceeding. In anxious patients, or if technical difficulties are anticipated, sedation is useful. It is not necessary to incise the skin to perform an aspirate but for a trephine biopsy a preliminary skin incision is desirable. This can be done either with a lancet or with the sharp edge of the hollow needle that has been used for injection of local anaesthetic. The biopsy needle should be firmly fixed in the cortex of the bone before the trocar is removed, to avoid including extraneous tissues in the biopsy specimen. Ideally, the biopsy should measure at least 20 mm in length after processing. A large biopsy is particularly important if there is a possibility of a focal lesion—for example, lymphomatous infiltrate, metastatic carcinoma, or granulomas. Trephine biopsies should be carried out only by appropriately trained personnel, usually consultant haematologists or haematopathologists or trainees in these disciplines. Trephine biopsies can be carried out safely on patients with severe thrombocytopenia but prolonged pressure is indicated to achieve primary haemostasis and reduce bruising to a minimum. If technical difficulties are anticipated—for example, if a patient with thrombocytopenia is also obese—it is usually possible to delay the procedure until a platelet transfusion has been given to raise the platelet count above 15 x 10⁹/litre. Bleeding problems are more likely in patients with coagulation defects and, if patients with severe liver disease or disseminated intravascular coagulation require a biopsy, the coagulation defect should be corrected, as far as possible, before the procedure is undertaken. If a biopsy appears to be indicated in a patient who is fully anticoagulated, and in whom cessation of anticoagulation is contraindicated, the clinical situation should be re-assessed to determine whether a trephine biopsy is essential for management or whether a bone marrow aspirate or an alternative diagnostic procedure might yield sufficient diagnostic information. All patients require an explanation of the purpose of the investigation and how the procedure will be carried out. Written consent should be obtained if the procedure is to be carried out under general anaesthesia or heavy sedation. Oral consent is usually considered sufficient if the patient will be fully conscious during the biopsy but local hospital policy should be followed in this regard. Trephine biopsies of the posterior superior iliac spine can be carried out successfully in children and adults. A modified technique applicable to the tibia has been described for neonates^ref. A core of bone is cut with a hollow needle and the specimen is then aspirated into a syringe; marrow structure is preserved and although the specimen contains small spicules of bone it can be processed without decalcification.
Adequacy of biopsy : it has been suggested that an adequate trephine biopsy specimen should contain at least 5-6 intertrabecular spaces and, after processing, should be at least 2–3 cm in length (Bain BJ, Clark DC, Lampert IA, et al. Bone marrow pathology, 3rd ed. Oxford: Blackwell Science, 2001). Others have considered that 1.5–2 cm is an acceptable length^ref (Islam A. Manual of bone marrow examination. Amsterdam: Overseas Publishers Association, 1997). Any such statement as to "adequate" length is arbitrary because the larger the amount of tissue that is biopsied the greater is the likelihood of focal lesions being detected^{ref1, ref2}. The amount of assessable haemopoietic marrow included in the biopsy specimen is of more importance than the total length. Evidence as to the relation between length and adequacy was provided by Bishop et al^ref. They demonstrated that the likelihood of detecting a metastatic tumour increased as the length of interpretable biopsy specimen increased from 0–0.04 mm to > 2 cm, but there was little further gain above a length of 1.2 cm; biopsy specimens of > 2 cm contained tumour in 30% of cases in comparison with biopsy specimens of 0.8–1.2 cm, 26% of which contained tumour. Measurements given relate to a biopsy specimen that has been paraffin wax embedded and decalcified because biopsy specimens shrink by about 25% during processing. It may reasonably be concluded that a biopsy specimen should measure at least 1.6 cm before processing, but that there will be a higher rate of detection of focal lesions with larger biopsies. In the case of children, biopsies will necessarily be shorter. There are no data on which to base advice as to adequacy. In the case of neuroblastoma, it has been suggested that an adequate biopsy should either contain tumour or have at least 0.5 cm of well preserved bone marrow^ref. Even this standard may not be achieved in as many as 25% of biopsies^ref. A higher detection rate with bilateral biopsies has been demonstrated for neuroblastoma^ref, small cell carcinoma of the lung^ref, Hodgkin's disease^{ref1, ref2},non-Hodgkin's lymphoma^{ref1, ref2, ref3}, other malignant disease^ref, and malignant disease in general (Alvarez CJ, Kidd PG, Ettinger LJ. Evaluation of bilateral bone marrow specimens in pediatric disorders. Am J Clin Pathol 1999;112:559). The higher detection rate for bilateral biopsies may be merely a reflection of the larger amount of tissue biopsied, although there is some evidence of a higher detection rate with bilateral biopsies than with 2 biopsies from the same side.^ref However, the gains from bilateral biopsies may not be very great. In a total of 567 patients with NHL reported in 3 large series of patients^{ref1, ref2, ref3}, there was detectable bilateral infiltration in 25% and unilateral in 10% of cases. If one postulates that there is an equal chance of the first of 2 biopsies being positive or negative in a patient with unilateral detectable disease, then approximately 5% of patients will have disease detected only in the second of 2 biopsies. The proportion of patients in whom disease management is altered by the second biopsy is likely to be < 5%. A reasonable compromise, given that patient discomfort must be considered in addition to the likelihood of gaining extra useful information, would be to measure the size of the biopsy specimen and to perform a second biopsy, preferably from the contralateral iliac crest, whenever the length of the initial unprocessed specimen is less than 1.6 cm and the results of the procedure would be likely to alter the management of the patient.
Processing of biopsy specimens and staining of sections : if an adequate aspirate has not been obtained it is useful to make a touch imprint of the biopsy specimen, for cytological examination, before putting it into fixative. This is done by rolling the specimen gently along a slide and permits a differential count similar to that performed on aspirate films^ref. If an imprint is not needed, the biopsy specimen should be placed immediately in fixative and when adequately fixed should be decalcified and processed further (Bain BJ, Clark DC, Lampert IA, et al. Bone marrow pathology, 3rd ed. Oxford: Blackwell Science, 2001). Plastic embedding of trephine biopsy specimens, which can then be sectioned without decalcifying, gives very good cytological detail. However, excellent results can also be obtained from paraffin wax embedded biopsy specimens if they are processed carefully and if sections are thin (< 4 µm and preferably considerably less). All biopsy specimens should have sections stained with haematoxylin and eosin (H&E) and for reticulin.
• a Giemsa stain on all specimens is also highly desirable because it yields information not available from an H&E stain. Specifically, a Giemsa stain permits the recognition of mast cells, highlights the presence of increased numbers of plasma cells or eosinophils, and helps in making a distinction between myeloblasts and proerythroblasts. It also aids the detection of abnormal bone structure. The effort needed to achieve consistently good Giemsa stains is worthwhile for the extra information yielded.
• an iron stain (Perls' stain) is unreliable on decalcified specimens because some or all of the iron may be removed during decalcification. However, if iron is detected this information can be of use. Either an iron stain can be performed in all cases or this stain can be applied selectively when it appears relevant—for example, if no adequate aspirate was obtained. In either event, it is necessary to remember that absence or apparent reduction of stainable iron in sections of a decalcified trephine biopsy specimen is not relevant and the report should therefore be worded carefully. The report should state "the iron stain is negative" rather than "storage iron is absent". The statement that "storage iron is reduced" cannot (and therefore should not) be made in relation to a decalcified biopsy specimen.
Most laboratories cut only the number of sections they intend to stain. A superior approach, but one that is not often followed on grounds of cost, is that of sectioning the entire block and H&E staining 20 representative sections (5/slide) from different levels in the biopsy specimen^ref. If a focal lesion is detected it is then possible to select the section adjacent to the section of interest for immunohistochemistry.
• granulomas^ref
• fibrin-ring granulomas are an infrequent pathological finding limited to liver and bone marrow specimens; they may appear (solid arrows) doughnut-like because they contain a lipid vacuole (open arrow) surrounded by a fibrinoid ring (H&E)
• Coxiella burnetii (usually)^{ref1, ref2, ref3, ref4, ref5, ref6, ref7}
• HHV-4 / EBV
• HHV-5 / CMV
• mycobacterial infections
• lymphoma
• vasculitis
• Salmonella typhi

Immunohistochemical stains should be applied selectively using appropriate methods of antigen retrieval when necessary :

CD3, CD1a, CD5, CD8	detection of T cells and T cell subsets (note: CD5 is also expressed on some B cells and B cell neoplasms and CD1a on Langherhan's cells)
CD20, CD79a, CD10, CD23	detection of B cells and B cell subsets
terminal deoxynucleotidyl transferase (TdT)	detection of immature cells in most acute lymphoblastic leukemias and some acute myeloid leukaemias
CD34	detection of immature cells in acute and chronic leukaemias and some cases of myelodysplastic syndrome (also useful for accentuation of vessels)
myeloperoxidase, neutrophil elastase, CD68	detection of granulocytic and monocytic differentiation
glycophorin	detection of erythroid cells
CD61 or von Willebrand's factor	detection of megakaryocytes
light chains (k or l)	detection of isotype restriction (and therefore probably monoclonality) in multiple myeloma, MGUS, lymphoplasmacytoid lymphoma, and amyloidosis
CD15	confirmation of Reed-Sternberg and mononuclear Hodgkin's cells
CD30	detection of infiltration by anaplastic large cell lymphoma and Reed-Sternberg and mononuclear Hodgkin's cells
CD31	endothelial cells (macrophages, monocytes, megakaryocytes, and plasma cells are also positive)
cyclin D1	detection of mantle cell lymphoma
ALK1	detection of anaplastic large cell lymphoma
epithelial membrane antigen	detection of infiltration by carcinoma cells or anaplastic large cell lymphoma
cytokeratin, prostate specific antigen, prostatic acid phosphatase	diagnosis of infiltration by carcinoma cells
CD1a	diagnosis of Langherhan's cell histiocytosis
mast cell tryptase	detection of mast cells and diagnosis of systemic mastocytosis
HMB45 and melan A (S100 less specific)	melanoma
vimentin, desmin, actin, myoglobin, chromogranin A, protein gene product 9.5, neuron-specific enolase (NSE)	differential diagnosis of small cell tumours of childhood

Examining and reporting a trephine biopsy, including areas of controversy
• who should report a trephine biopsy ? The question of who should report a trephine biopsy is problematical. Ideally, this should be done by a haematopathologist who has been trained adequately in both laboratory haematology and histopathology and who is also competent to assess blood films and bone marrow aspirates. Problems arise in countries where haematologists and histopathologists are narrowly trained in their specific disciplines and do not have a broad area of competence. In such circumstances, the haematologist may be more reliable at interpreting the trephine biopsy specimen in patients with acute and chronic leukaemias, myelodysplastic syndromes, and myeloproliferative disorders, whereas the histopathologist may be more competent at diagnosing fungal and mycobacterial infection and interpreting infiltration by non-haemopoietic tumours. In addition, the practical reality of the situation is that, except when there is a very large volume of haematopathological specimens justifying a separate laboratory, biopsy specimens are likely to be processed by a histopathology laboratory even if the stained sections are then presented to a haematologist for assessment. The lack of a single group of pathologists with the training and experience to interpret blood films, bone marrow aspirates, and trephine biopsy specimens is hardly ideal but should be acknowledged and the practical problems created should be confronted. The only solution is close cooperation between disciplines. Ideally, in this circumstance the blood film, bone marrow aspirate, and trephine biopsy specimens should be examined simultaneously by a haematologist and histopathologist working together. If the workload of either does not permit this for all specimens then the minimum acceptable safeguard is that the histopathologist should not release a report on a trephine biopsy without ascertaining the haematologist's opinion on the blood film and bone marrow aspirate. If there is any apparent discrepancy between the findings this should be resolved by a joint examination of the slides of the case or, at the very least, by a telephone conversation between those responsible for reporting the specimens. Reports should only be issued by a qualified haematologist or histopathologist.
• evaluating a trephine biopsy specimen : H&E stained sections of the specimen should be examined systematically at low power (x2.5, x4, or x10 objective), at medium power (x20, x40, or x50 objective), and at high power (x100, oil immersion objective). Low power examination is important for evaluation of the adequacy of the biopsy specimen and for assessment of cellularity and the detection of focal lesions. A short piece of subcortical bone marrow is totally inadequate for assessment because it is likely to be of low cellularity. Focal lesions that may be noted at low power include granulomas and focal infiltrates of lymphoma cells or carcinoma cells. Examination at low to medium power permits assessment of cellularity, bone structure, and megakaryocyte numbers. At medium power the location of cells of erythroid and granulocytic lineages and their relative proportions can be assessed, the nature of any focal lesions can be determined, and blood vessels can be examined. Examination at high power is important if fine cellular detail is to be appreciated and if fungal and protozoal infections are to be detected. Although cryptococci are usually readily detected at medium power, histoplasmosis—particularly in patients with a poor immune response as a consequence of AIDS—can easily be missed if high power examination is omitted. The correct diagnosis of acute leukaemia, the myelodysplastic syndromes, megaloblastic anaemia, and lymphoma requires high power examination. After examination of the H&E stained sections, the Giemsa stain, reticulin stain, and iron stain should be examined. The reticulin should be graded, according to a standardised published system, and any focal increase in reticulin deposition should be noted. The presence of focal reticulin deposition is an indication to re-examine the H&E stained sections in case a focal infiltrate or a granuloma has been missed. After routine stains have been examined a decision should be made as to whether any specialised cytochemical stains (such as Congo red staining or Ziehl-Neelsen stain) or immunohistochemical stains are needed.
• reporting a trephine biopsy specimen : the trephine biopsy report should begin with a macroscopic description and, usually, a statement that the specimen was embedded in its entirety. Usually, the length of the biopsy is the only useful information to be gained, but occasionally the biopsy specimen is macroscopically abnormal. The report of the microscopical appearances should begin with a statement as to the size of the specimen or its adequacy for diagnosis and should then comment systematically on cellularity, bone structure, haemopoietic cells, and any abnormal infiltrate. Special stains, if any, should be assessed and commented on. The report should finish with a summary of the abnormalities detected and their likely importance. At this stage, if not earlier, the haematologist or histopathologist should have examined or ascertained the findings on the bone marrow aspirate and, if assessment of cytological and histological features is consistent, should issue a report. If it is necessary to issue a provisional report—for example, because special stains are pending or because a second opinion is being sought—this should be clearly stated. Laboratories must have procedures in place to ensure that unauthorised provisional reports are not inadvertently released to clinical staff. It is useful for laboratory staff if all provisional reports on laboratory computers are clearly indicated as "UNAUTHORISED REPORT" so that laboratory staff referring to them are instantly aware of their status. At the point when a report has been finalised and authorised the name of the pathologist issuing the report must be added, either as a signature or by computer authorisation using a secure password system^ref.
With motivated staff and a structured educational and training programme it is possible for nurse practitioners to perform the techniques of bone marrow aspiration and biopsy, and obtain specimens of satisfactory quality (78% good smears vs. 91% for those prepared by doctors), thus improving efficiency of the haematology day unit and increasing quality of patient care.trained. It is well known that
satisfactory spreading of blood or bone marrow films requires practice. This problem is lessening as the nurses become more experienced, and we anticipate that it will disappear altogether. Before the nurses had become competent at slide preparation, problems were easily overcome by placing a 2 ml sample of aspirated marrow in a specimen bottle containing EDTA so that smears could also be
prepared by the medical or haematology laboratory staff. If the spread is done within 8 hours this does not cause EDTA artefact, and
we have not found dilution with peripheral blood to be a problem^ref. An earlier study from Manchester has shown that trephine biopsies shrink by 25% during processing and that for the diagnosis of neoplasia a minimum prefixation trephine length of 16 mm is required^ref. The National Cancer Institute (NCI) has recommended a bone marrow biopsy length of >/=20 mm for the staging and surveillance of patients with non-Hodgkin's lymphoma.
• transthoracic lung needle biopsy in an intercostal space
• open lung biopsy (OLB)
• liver biopsy is performed to evaluate elevated liver enzymes with the goal of confirming, excluding or assessing the severity (staging) of liver disease. Occasionally it may be performed to diagnose abnormalities in the liver seen on imaging studies such as ultrasonography, CT scans or MRI scans. Common clinical problems requiring a liver biopsy are infectious hepatitis (Hepatitis B and C) and fatty liver. Less commonly, a liver biopsy may be performed to evaluate autoimmune hepatitis, iron or copper overload, liver mass, medication related liver problems and in following a liver transplant patients. The liver biopsy can be performed through the skin (percutaneous), via major blood vessels that pass through the liver (transjugular) or during abdominal surgery. The percutaneous approach is the most common means of obtaining a sample of liver tissue. The procedure is typically performed in the outpatient setting. Ultrasonography may be used to locate a good site for biopsy. The chosen site is numbed with local anesthetic and tissue sample is obtained with a long needle passed into the liver. The actual biopsy portion of the procedure takes several seconds. If the goal is to obtain tissue from a particular abnormal area, the biopsy can be performed under the guidance of either echography or CT.

Contraindications :
• hypocoagulation
• inability to identify a good site for percutaneous biopsy
• marked obesity
• severe cough
• prolonged cholestatic jaundice
In these patients liver tissue can be obtained via a catheter that is passed into the a large vein in the neck and advanced to the liver. A sample of liver tissue can also be obtained during laparoscopic or open abdominal surgery. The tissue obtained undergoes special staining procedures. Subsequently the pathologist renders a diagnosis after microscopic examination. Risks include injury to surrounding organs, bleeding or a bile leak and may require observation in the hospital.
• renal biopsy

Contraindications :
• kidney size < 9 cm
• tumors
• hydronephrosis
• uncorrectable hemorrhagic diatesis
• single kidney
• uncontrolled severe systemic arterial hypertension or hypotension
• bilateral multiple renal cysts
• renal cancers
• hydronephrosis
• infectious nephritis or perinephritis
• nerve biopsy

Method : usually the sural, superficial peroneal or superficial radial sensory nerves are chosen for biopsy. Motor nerves or their branches are usually not selected.
Indications :
• in general, in only select cases of peripheral nerve disease:
• of little help in early detection or monitoring of neuropathy
• not indicated for typical neuropathies from clearcut etiologies (diabetes, alcoholism)
• findings are nonspecific in chronic, distal, axonal, symmetrical neuropathies
• systemic illness associated with multiple mononeuropathies (amyloidosis, leprosy, sarcoidosis and vasculitis---in the latter two, simultaneous muscle biopsy increases diagnostic yield)
• inflammatory or dysimmune neuropathies
• demyelinating neuropathies
• inherited, metabolic neuropathies (metachromatic leukodystrophy, Krabbe's disease, adrenoleukodystrophy, Fabry's disease) if blood or other tests nondiagnostic
No specific contraindications are present, other than those to be considered in the performance of any operative technique. A biopsy should not be done if expertise with the handling, preparation and analysis of the nerve specimen is not available.
Complications : few are encountered, but local infection, persistent paresthesias or neuroma formation can result.
• muscle biopsy

Method: the procedure is usually performed as an open biopsy and the muscle tissue removed is placed into clamps that lightly stretch the specimen. The biceps, triceps or deltoid muscles in the upper extremity and the vastus lateralis or gastrocnemius muscles in the lower extremity are typically chosen for biopsy.
Indications :
• inflammatory myopathies
• congenital or hereditary myopathies (muscular dystrophies)
• metabolic myopathies
• mitochondrial myopathies
No specific contraindications are present, other than those to be considered in the performance of any operative technique. A biopsy should not be done if expertise with the handling, preparation and analysis of the muscle specimen is not available.
Complications : few are encountered other than local infection.
• brain biopsy

Method: usually performed when less invasive methods have been unsuccessful in providing a diagnosis, which is needed to guide future management. The biopsy is usually performed either through a small craniotomy or via a burr hole, often with the use of stereotaxic (CT or MRI) guidance (stereotactic biopsy). Patients underwent biopsy with straight local anesthesia only (2% Lylocaine) further facilitated by i.v. sedation (Dormicum 5 mg). Samples are obtained as serial stereotactic biopsies with 6-10 specimens taken from each patient. Intra-operative smear preparations are routinely performed on several alternate specimens and reported by an experienced neuropathologist. Specimens are stained with methylene blue. Alternate specimens are fixed in 10% neutral buffered paraformaldehyde solution and subsequently embedded in paraffin for further histochemical processing^ref
Indications :
• diagnosis of a primary or metastatic brain tumor
• CNS vasculitis
• infection (infrequently performed)
• degenerative disorders (infrequently performed)
Contraindications :
• deep or poorly localized lesions
• surgically inaccessible lesions
Complications :
• adverse effects of anesthesia or the surgical procedure itself
• hemorrhage
• seizure
• unexpected worsening of the neurological deficit due to brain injury during the procedure
• brain edema
Guidance :
• echography (the only real-time guidance) : liver, pancreas, kidney


• CT : retroperitoneal organs, adrenals (echography if slim); requires definition of cutaneous landmark and angle of injection.
• MRI (nonferromagnetic needles)
Complications (0.1-0.2%) :
• hemorrhages
• neoplastic seeding
Prevention :
• defined indications (only if previous imaging has been unconclusive)
• verify hemocoagulative status (platelet > 50,000/mL and QT > 50% are required)
• written informed consent
• lithotomy : incision of a duct or organ, especially of the bladder, for removal of stone.
• bilateral lithotomy : one performed by a transverse incision across the perineum.
• prerectal or median lithotomy : one in which the incision is made on the raphe of the perineum anterior to the anus.
• lateral lithotomy : one in which the incision is before the rectum and to one side of the raphe.
• mediolateral lithotomy : a combination of the median and lateral operations.
• perineal lithotomy : that in which the incision is made in the perineum.
• rectal or rectovesical lithotomy : one performed by an incision within the dilated rectum.
• high or suprapubic lithotomy : one performed by an incision above the pubes.
• vaginal or vesicovaginal lithotomy : one performed by an incision within the vagina.
• curettage / curettement : the removal of growths or other material from the wall of a cavity or other surface, as with a curet / curette (a spoon-shaped instrument for removing material from the wall of a cavity or other surface; Hartmann's curet : an instrument for removing adenoids)
• débridement : the removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed. Cf. .
• enzymatic débridement : removal of fibrinous or purulent exudate by application of a nontoxic and nonirritating enzyme that is capable of lysing fibrin, denatured collagen, and elastin but does not destroy normal tissue.
• surgical débridement : débridement by mechanical methods, usually sharp dissection.
• épluchage : removal of the contused and contaminated tissues of a wound
• sonic surgery : the use of focused ultrasonic waves to produce precisely circumscribed alterations within tissues at predetermined sites
• conservative surgery : surgery designed to preserve, or to remove with minimal risk, diseased or injured organs, tissues, or extremities
• radical operation or surgery : surgery designed to extirpate all areas of locally extensive disease and adjacent zones of lymphatic drainage
• adhesiotomy : the cutting or division of adhesions.
• cystectomy : excision of a cyst.
• diverticulopexy : surgical fixation of a diverticulum in a new position following its separation from the initial adjacent or adherent structures.
• diverticularization : the act of forming diverticula or pockets
• diverticulectomy : excision of a diverticulum
• tumorectomy : an imprecise term usually used to denote either debulking or removal of most or all of a primary tumor, particularly of the breast, with only minimal removal of surrounding tissue
• metastasectomy : excision of one or more metastases
• sphincterectomy : excision of any sphincter, such as the sphincter iridis
• sphincteroplasty : surgical repair of a defective sphincter
• sphincterotomy : division of a sphincter
• internal sphincterotomy : incision of the internal anal sphincter.
• head surgery
• neurosurgery : surgery of the nervous system.
• functional neurosurgery : neurosurgery designed to restore physiological activity of nerves, such as by enhancing conductivity of nerve fibers or improving blood flow to nerve tissue.
• brain surgery
• Ommaya reservoir : a device implanted beneath the galea aponeurotica for instillation of medication or removal of fluid through a catheter positioned in a lateral ventricle of the brain
• psychosurgery / psychiatric or functional neurosurgery : brain surgery performed for treatment of psychiatric disorders, e.g. dorsomedial thalamotomy
• ventriculostomy : the operation of establishing a free communication or shunt between the floor of the third ventricle and the underlying cisterna interpeduncularis; for the treatment of hydrocephalus.
• ventriculostium : an artificial opening created between one of the cerebral ventricles and the external surface of the brain
• ventriculoatrial shunt : the surgical creation of a communication between a cerebral ventricle and a cardiac atrium by means of a plastic tube with an in-line pressure-flow regulator, to permit drainage of cerebrospinal fluid for relief of hydrocephalus.
• ventriculocisternal shunt / Torkildsen's shunt or operation / ventriculocisternostomy : an obsolete procedure in which a communication is surgically established between a lateral ventricle and the cisterna magna for drainage of cerebrospinal fluid in hydrocephalus; of historic interest
• ventriculoperitoneal shunt : the most common shunting procedure for the relief of hydrocephalus, consisting of the creation of a channel between a cerebral ventricle and the peritoneum by means of plastic tubing.
• ventriculopleural shunt : a communication between a cerebral ventricle and the pleural cavity by means of a plastic tube with an in-line pressure-flow regulator, done for the relief of hydrocephalus.
• ventriculovenous shunt : creation of a communication between a cerebral ventricle and the internal jugular vein by means of a plastic tube with an in-line pressure-flow regulator, to permit drainage of cerebrospinal fluid for relief of hydrocephalus
• ventriculotomy : incision of a ventricle of the brain
• pallidectomy : surgical excision of the globus pallidus or extirpation of it by other means (chemopallidectomy).
• pallidoansection : surgical section of the globus pallidus and ansa lenticularis.
• pallidoansotomy : production of lesions in the globus pallidus and ansa lenticularis.
• pallidotomy : a stereotaxic surgical technique for producing lesions in the globus pallidus for treatment of extrapyramidal disorders.
• craniectomy : excision of a part of the skull.
• hemicraniectomy : exposure of half of the brain by sectioning the vault of the skull from front to back near the median line and forcing the entire side outward.
• craniotomy : any operation on the cranium; incision into the cranium.
• craniamphitomy : division of the entire circumference of the skull to secure decompression
• cranioplasty : any plastic operation on the skull; surgical correction of defects of the skull
• craniotrypesis : trephination of the skull.
• stereotactic or stereotaxic surgery / stereoencephalotomy / stereotaxy / stereotactic neurosurgery : any of several techniques for the production of sharply circumscribed lesions in specific tiny areas of pathologic tissue in deep-seated structures of the CNS. The site to be worked on is localized with 3D coordinates; precise images, obtained usually with computed tomography or magnetic resonance imaging may be compared with those in a stereotactic atlas. An arc guidance system is used to direct the electrode or other lesion-producing instrument; methods of producing lesions include heat, cold, X-rays (stereotactic radiosurgery (SRS)), and ultrasound
• arc guidance system : an apparatus used in stereotactic surgery consisting of a metal arc-shaped band or bar with degree markings and an attachment for an electrode that is positioned by moving through the arc to aim at a precise location in the brain
• arc-quadrant : an arc guidance system that has a 90° arc
• Brown-Roberts-Wells technique : a ring to hold the head in position, a ring for localization of a CT image, and an arc guidance system (Brown-Roberts-Wells apparatus)
• Leksell technique : an arc guidance system and a cube-shaped frame that holds the head in position and is marked with X, Y, and Z coordinates for 3D orientatio (Leksell apparatus)
• Riechert-Mundinger technique : a semicircular arc guidance system and a ring to hold the head in position (Riechert-Mundinger apparatus)
• Todd-Wells technique : an arc-quadrant, a ring around the head to steady the head and provide one set of reference angles, and a ring around the neck to provide a second set of reference angles (Todd-Wells apparatus)
• corpuscallosotomy / corpus callosotomy : surgical transection of the fibers in the corpus callosum, done to gain access to third ventricular structures; formerly used to treat intractable epilepsy
• topectomy / corticectomy / frontal gyrectomy : ablation of a small and specific area of the frontal cortex, for the treatment of certain forms of epilepsyand psychiatric disorders
• hemicorticectomy : excision of a cerebral hemisphere leaving the basal ganglia intact; done in intractable epilepsy.
• lobotomy : incision into a lobe; in psychosurgery, surgical incision of all the fibers of a lobe of the brain.
• prefrontal or frontal lobotomy or leukotomy : an operation in which, through holes drilled in the skull, the white matter of the frontal lobe is incised with a leukotome passed through a cannula
• transorbital lobotomy or leukotomy : prefrontal lobotomy performed by way of the orbital plate
• lobectomy : excision of a lobe, as of the thyroid, liver, brain, or lung
• occipital lobectomy : removal of the occipital lobe, to treat brain cancer or occasionally epilepsy with a focus in the occipital lobe.
• sleeve lobectomy or resection : excision of a lobe of the lung with removal of a portion of the bronchus and reanastomosis of the resulting ends
• temporal lobectomy : excision of part or all of a temporal lobe in the treatment of temporal lobe epilepsy.
• lesionectomy : the surgical removal of a discrete lesion within the cerebral cortex while sparing the surrounding tissue; used in the treatment of epilepsy.
• hemispherectomy : resection of a cerebral hemisphere

Indications :
• intractable childhood epilepsy
• hemimegalencephaly
• severe brain infection
• severe brain ischemia
• severe brain trauma
• Sturge-Weber syndrome
• Rasmussen's encephalitis
• hemicraniectomy : exposure of half of the brain by sectioning the vault of the skull from front to back near the median line and forcing the entire side outward.
• hemidecortication : removal of one half of the cerebral cortex.
• hemicorticectomy : excision of a cerebral hemisphere leaving the basal ganglia intact; done in intractable epilepsy.
• Horsley's operation : excision of an area of motor cortex for relief of athetoid and convulsive movements of an upper extremity; of historical interest.
• thalamotomy : a stereotaxic surgical technique for the discrete destruction of specific groups of cells within the thalamus; done to relieve pain, to alleviate the tremor and rigidity in Parkinson's disease (PD)
• anterior thalamotomy : production of lesions in the anterior nucleus of the thalamus.
• dorsomedial thalamotomy : production of lesions in the dorsomedial nucleus of the thalamus, a psychosurgical technique for the relief of certain anxiety states, psychoses, and obsessive-compulsive states
• hypophysectomy / pituitectomy : surgical removal or destruction of the hypophysis (pituitary gland)
• cerebral decompression : removal of a flap of the skull and incision of the dura mater for relief of intracranial pressure.
• suboccipital decompression : cerebral decompression by occipital craniectomy and opening of the dura.
• subtemporal decompression : cerebral decompression by removal of a portion of the temporal bone and opening of the dura.
• Jannetta procedure / microvascular decompression : a microsurgical procedure for relief of trigeminal neuralgia; decompression of the sensory root of the trigeminal nerve is accomplished by insertion of a small nonabsorbable sponge to relieve pressure from small blood vessels where the root enters the pons
• duraplasty : a plastic operation on the dura mater; graft of the dura.
• eye surgery
• enucleation : removal of the eyeball after the eye muscles and optic nerve have been severed
• removing metal particles from the eye
• Grüning's magnet : one made up of a number of steel rods
• Haab's magnet : a powerful magnet
• Hirschberg's magnet : an electromagnet
• scleronyxis : surgical puncture of the sclera.
• scleral buckling : a technique for repair of detachment of the retina, in which indentations or infoldings of the sclera are made over the tears in the retina so as to promote adherence of the retina to the choroid.
• sclerectomy : excision of the sclera by ...
• sclerectome : an instrument for performing sclerectomy.
• sclerectoiridectomy / Lagrange's operation : the operation of excision of a portion of the sclera by scissors and of the iris for glaucoma
• Elliot's operation : a method of trephining the sclerocornea for the relief of increased tension in glaucoma.
• Holth's operation : excision of the sclera by punch operation.
• sclerectoiridodialysis : sclerectomy and iridodialysis.
• vitrectomy : surgical extraction usually via the pars plana of the contents of the vitreous chamber of the eye
• keratectomy : excision of a portion of the cornea, usually done for anterior staphyloma
• corneal abscission : excision of the prominence of the cornea in staphyloma
• keratoleptynsis : removal of the anterior portion of the cornea and covering of the denuded area with bulbar conjunctiva.
• keratotomy / kerectomy  : surgical incision of the cornea.
• Gifford's operation / delimiting keratotomy : incision of the cornea in ulcus serpens by a cut tangential to the advancing border of the ulcer and made to emerge at a corresponding point in the other side.
• radial keratotomy : an operation in which a series of incisions is made in the cornea from its outer edge toward its center in spokelike fashion; done to flatten the cornea and thus to correct myopia.
• keratoplasty : plastic surgery of the cornea; corneal grafting.
• autogenous keratoplasty / autokeratoplasty : corneal grafting with tissue from the patient's other eye
• heterokeratoplasty : grafting of corneal tissue from an individual of a species other than that of the recipient.
• lamellar keratoplasty : a transplant of the anterior half of the cornea with the anterior chamber remaining intact.
• optic keratoplasty : transplantation of corneal material to replace scar tissue which interferes with vision.
• penetrating keratoplasty : a transplant of a section of full-thickness cornea.
• refractive keratoplasty : that in which a section of cornea is removed from the patient or a donor, shaped to the desired curvature, and inserted either between (keratophakia) layers of or on (keratomileusis) the patient's cornea to change its curvature and correct optical errors.
• tectonic keratoplasty : transplantation of corneal material to replace tissue which has been lost.
• keratophakia : a form of keratoplasty in which a slice of donor's cornea is shaped to a desired curvature and inserted between layers of the recipient's cornea to change its curvature.
• epikeratophakia : overlaying of a piece of donor cornea on the patient's cornea to change its curvature in order to correct refractive error
• keratomileusis : keratoplasty in which a slice of the patient's cornea is removed, shaped to the desired curvature on a lathe after freezing, and then sutured back on the remaining cornea to correct optical error.
• laser-assisted in-situ keratomileusis (LASIK) : keratoplasty in which the excimer laser and microkeratome are combined for vision correction; the microkeratome is used to shave a thin slice and create a hinged flap in the cornea, the flap is reflected back, the exposed cornea is reshaped by the laser, and the flap is replaced, without sutures, to heal back into position
• Ammon's operation / dacryocystotomy : incision of the lacrimal sac.  2. for epicanthus: resection of a spindle-shaped piece of skin over the bridge of the nose, undermining the flaps of the epicanthal fold and closing with sutures.
• Anagnostakis' operation : an operation for entropion.  2. an operation for trichiasis.
• Barkan's operation / goniotomy : an operation for glaucoma characterized by an open angle and normal depth of the anterior chamber; it consists of the opening of Schlemm's canal under direct vision secured by a contact glass.
• gerontotoxon lentis : equatorial couching of the lens in the aged; no longer done
• Barraquer's method or operation / phacoerysis : removal of the lens in cataract by means of suction with an instrument known as an erysiphake
• phacocystectomy : excision of a portion of the capsule of the lens for cataract
• phacoemulsification : a method of cataract extraction in which the lens is fragmented by ultrasonic vibrations and simultaneously irrigated and aspirated
• phacolysis : discission of the crystalline lens, followed by extraction
• Daviel's operation : extraction of cataract through a corneal incision without cutting the iris.
• Beer's operation : a flap method for cataract.
• Berke operation : an operation for ptosis of the upper eyelid, consisting of (1) a modification of the Blaskovics operation, with resection of the levator muscle through a skin incision and excision of excess muscle, or (2) a modification of the Motais operation, with suspension of the ptotic lid from the superior rectus muscle.
• Blaskovics operation : an operation for ptosis of the upper eyelid, consisting of excision of the levator muscle and the tarsus through a conjunctival approach.
• equilibrating operation : tenotomy of the direct antagonist of a paralyzed eye muscle.
• Eversbusch's operation : an operation for ptosis of the upper eyelid, consisting of resection of the levator muscle through a skin incision.
• Frost-Lang operation : insertion of a gold ball to take the place of an enucleated eyeball.
• Fukala's operation : removal of the lens of the eye for the treatment of marked myopia.
• Gonin's operation : treatment of retinal detachment by thermocautery of the fissure in the retina performed through an opening in the sclera.
• Graefe's operation : removal of the cataractous lens by a scleral cut, with laceration of the capsule and iridectomy.
• Gillies operation : operation for correction of ectropion utilizing a split-thickness skin graft and a mold
• cyclodialysis : operative formation of a communication between the anterior chamber of the eye and the suprachoroidal space; done in the treatment of glaucoma.
• Heine's operation : cyclodialysis in glaucoma
• cyclodiathermy : destruction of a portion of the ciliary body by diathermy; employed as therapy in cases of glaucoma.
• cycloduction : the duction of the eyeball produced by the oblique muscle
• cycloelectrolysis : electrolysis of the ciliary body, used to lower intraocular pressure in glaucoma.
• Herbert's operation : displacement of a wedge-shaped flap of sclera in order to form a filtering cicatrix in glaucoma.
• Krönlein's operation : resection of the outer wall of the orbit for the removal of an orbital tumor without excising the eye.
• Landolt's operation : the formation of a lower eyelid with a double pedicle or bridge flap of eyelid skin taken from the upper lid.
• Knapp's operation : (for cataract), the formation of a peripheral opening in the capsule behind the iris, without iridectomy.
• Motais' operation : an operation for ptosis, consisting of transplanting the middle portion of the tendon of the superior rectus muscle of the eyeball into the upper lid.
• Mules' operation : evisceration of the eyeball, with insertion of an artificial vitreous.
• Naffziger's operation : excision of the superior and lateral walls of the orbit for exophthalmos.
• Scheie's operation : scleral cauterization with peripheral iridectomy for treatment of glaucoma. Also a technique for needling and aspiration of cataract.
• Smith's operation : extraction of an immature cataract with an intact capsule.
• dacryocystostomy : surgical creation of a new opening into the lacrimal sac.
• Toti's operation / dacryocystorhinostomy / dacryorhinocystotomy : surgical creation of a communication between the lacrimal sac and the nasal cavity
• dacryocystorhinotomy : passage of a probe through the lacrimal sac into the nasal cavity.
• dacryoadenectomy : excision of a lacrimal gland
• dacryocystectomy : excision of the wall of the lacrimal sac.
• dacryocystitome / dacryocystotome : an instrument for incising strictures of the lacrimal duct
• Meller's operation : an operation for excision of the tear sac.
• magnet operation : removal of a fragment of steel or iron from the eyeball by means of a powerful magnet.
• Ziegler's operation : V -shaped iridectomy for forming an artificial pupil.
• Asch operation : an operation for deflection of the nasal septum by reinserting resected pieces of cartilage and holding them in place with a splint; of historical interest.
• Denonvilliers' operation : plastic correction of a defective ala nasi by transferring a triangular flap from the adjacent side of the nose.
• Lempert's fenestration operation : an operation for otosclerosis, consisting of drilling a small oval window (fenestra nov-ovalis) into the lateral semicircular canal and then placing a flap of skin over the fistula.
• Saemisch's operation : transfixion of the cornea and of the base of the ulcer for the cure of hypopyon.
• canthectomy : surgical removal of a canthus.
• cantholysis : surgical division of the canthus of an eye or of a canthal ligament.
• canthoplasty : plastic surgery of the medial and/or lateral canthus, especially section of the lateral canthus to lengthen the palpebral fissure; also the surgical restoration of a defective canthus.
• canthorrhaphy : the suturing of the palpebral fissure at either canthus.
• canthotomy : surgical division of the outer canthus.
• iridectomesodialysis : surgical formation of an artificial iris by excision and separation of adhesions around the inner edge of the iris
• iridectomy / corectomy : surgical excision of a full-thickness piece of the iris
• basal iridectomy : iridectomy at the base of the iris close to its attachment to the ciliary body.
• complete, sector or total iridectomy : surgical excision of a whole radial section of the iris from the root to, and including, the margin
• optic or optical iridectomy : excision of part of the iris as a means of enlarging an abnormally small pupil and improving vision.
• basal, buttonhole, peripheral or stenopeic iridectomy : a surgical treatment for narrow-angle glaucoma, and consisting of a full-thickness excision of a portion of the periphery or root of the iris, the pupillary border and sphincter muscle being left intact
• preliminary or preparatory iridectomy : iridectomy performed before removal of the lens in cataract surgery.
• therapeutic iridectomy : iridectomy performed for the cure of disease of the eye.
• iridectome : a cutting instrument for use in iridectomy
• iritoectomy : surgical excision of iritic deposits of after-cataract, together with iridectomy, to form an artificial pupil
• iridencleisis : the surgical creation of a permanent drain by incarceration of a slip of the iris within a corneal or limbal incision to act as a wick through which the aqueous is filtered from the anterior chamber to the subconjunctival tissues; done to reduce intraocular pressure
• iridesis : the operation of repositioning the pupil by bringing a sector of the iris through a corneal or limbal incision and fixing the sector with a suture.
• iridoavulsion : complete tearing away of the iris from its periphery.
• iridocorneosclerectomy : surgical excision of a portion of the iris, cornea, and sclera for glaucoma.
• iridocyclectomy : surgical removal of a portion of the iris and of the ciliary body.
• iridocystectomy : an operation to establish an artificial pupil in an eye in which the iris adheres to the residual lens capsule, accomplished by excising a portion of the iris and lens capsule through a corneal incision.
• iridodialysis : separation or loosening of the iris from its root at the ciliary body, either from trauma or from surgical accident.
• iridomesodialysis : surgical loosening of adhesions around the inner edge of the iris
• iridorhexis : the tearing away of the iris.
• iridosclerotomy : incision of the sclera and of the edge of the iris in treatment of glaucoma.
• iridotasis : the operation of stretching the iris in treatment of glaucoma.
• iridotomy : incision of the iris, as in creating an artificial pupil.
• sphincterolysis : the operation of separating the iris from the cornea in anterior synechia
• spinal cord surgery
• decompression of spinal cord : relief of pressure on the spinal cord by means of surgery
• microlaminectomy : excision of the posterior arch of a vertebra using an operative microscope or loupe for magnification.
• microdiskectomy : debulking of a herniated nucleus pulposus using an operating microscope or loupe for magnification.
• arthroscopic microdiskectomy : microdiskectomy performed with instruments introduced into the area of herniation through an arthroscope.
• cordotomy / chordotomy : interruption of the lateral spinothalamic tract of the spinal cord, usually in the anterolateral quadrant, for relief of intractable pain
• open cordotomy : cordotomy done through an open incision; now largely replaced by percutaneous cordotomy.
• percutaneous cordotomy : cordotomy performed using percutaneous electrodes guided radiographically with stereotactic techniques; approaches used include lateral high cervical, posterior high cervical, and anterior low cervical.
• nerve surgery
• nerve transposition :  the operation of carrying a nerve from one situation to another without severing its connection entirely until it is united at its new location.
• rhizotomy : interruption of a cranial or spinal nerve root
• anterior rhizotomy : division of the anterior or motor spinal nerve roots.
• chemical rhizotomy : rhizotomy by injection of a neurolytic chemical such as glycerol or phenol adjacent to the nerve root
• glycerol rhizotomy : chemical rhizotomy of the trigeminal or spinal nerves by injection of glycerol
• percutaneous rhizotomy : trigeminal rhizotomy not involving brain surgery, such as glycerol rhizotomy or percutaneous radiofrequency rhizotomy.
• percutaneous radiofrequency rhizotomy : trigeminal rhizotomy in which radio waves are used to destroy part of the trigeminal ganglion.
• posterior rhizotomy / dorsal rhizotomy : division of the posterior or sensory spinal nerve roots; done for relief of intractable pain
• trigeminal neurolysis or rhizotomy / retrogasserian rhizotomy : destruction of part of the sensory root of the trigeminal nerve above the trigeminal ganglion, or of the ganglion itself, for the relief of trigeminal neuralgia. The most common surgical techniques used are Dandy's operation (using an approach through the posterior cranial fossa) and the Frazier-Spiller operation (using an approach through the middle cranial fossa); nonsurgical techniques include percutaneous radiofrequency rhizotomy and glycerol rhizotomy
• Cotte's operation : removal of the presacral nerve.
• Krause's operation : extradural excision of the gasserian ganglion for trigeminal neuralgia; of historical interest.
• Hartley-Krause operation : excision of the gasserian ganglion and its roots to relieve trigeminal neuralgia; of historical interest.
• Körte-Ballance operation : anastomosis of the facial and hypoglossal nerves.
• neurolysis / nerve block : release of a nerve sheath by cutting it longitudinally or the operative breaking up of perineural adhesions or the relief of tension upon a nerve obtained by stretching.  4. destruction or dissolution of nerve tissue; sometimes done as a temporary or permanent measure for the relief of pain or spasticity
• intramuscular neurolysis / motor point block : interruption of impulses, by anesthesia or destruction of the nerve, at a motor point in order to relieve spasticity
• phenol motor point block / phenol block with a solution of 5% phenol in water is injected
• chemical neurolysis : neurolysis by injection of a neurolytic chemical such as glycerol, phenol, or alcohol adjacent to a nerve; see also chemical rhizotomy.
• intrathecal neurolysis : chemical neurolysis in which a substance is injected under the dura mater of the spinal cord.
• alcohol neurolysis : intrathecal neurolysis in which dehydrated alcohol is injected at the point where the dorsal root emerges from the spinal cord.
• phenol neurolysis : intrathecal neurolysis in which a solution of 5-7.5% phenol in glycerol is injected into a dorsal root ganglion.
• neurolytic celiac plexus block (NCPB) for patients with unresectable pancreatic cancer
• vagolysis : surgical destruction of the vagus nerve
• sympathectomy / sympathetectomy : the transection or other interruption of any part of the sympathetic nervous pathways. Operations may be named according to the location of the nerve, ganglion, or plexus operated on, as cervical, dorsal, lumbar, or thoracolumbar s., or in reference to the diaphragm, as subdiaphragmatic, supradiaphragmatic, or transdiaphragmatic s.
• sympathicotripsy : the surgical crushing of a nerve, ganglion, or plexus of the sympathetic nervous system
• neurorrhaphy : the suturing of a cut nerve.
• autoplastic transplantation :
• vagotomy : interruption of the impulses carried by the vagus nerve or nerves.
• bilateral vagotomy : transection of the right and left vagus nerves.
• truncal vagotomy : surgical division of the 2 main trunks of the abdominal vagus nerve as they emerge through the esophageal hiatus
• selective vagotomy : division of the vagal fibers to the stomach with preservation of the hepatic and celiac branches.
• parietal cell vagotomy : selective severing of the vagus nerve fibers supplying the proximal two-thirds (parietal area) of the stomach; done for duodenal ulcer.
• highly selective vagotomy : division of only those vagal fibers supplying the acid-secreting glands of the stomach, with preservation of those supplying the antrum as well as the hepatic and celiac branches.
• posterior truncal vagotomy : a variation of the highly selective vagotomy in which the posterior vagal trunk is surgically cut for treatment of severe intractable gastric ulcers.
• medical vagotomy : interruption of the impulses carried by the vagus nerve by administration of suitable drugs; vagus block.
• nerve decompression : relief of pressure on a nerve by surgical removal of the constricting fibrous or bony tissue.
Web resources :
• Neurosurgery
• American Association of Neurological Surgeons (AANS)
• Congress of Neurological Surgeons (CNS)
• Neurosurgery://On-Call
• Cerebrovascular surgery
• History of neurosurgery
• Neurotrauma & Critical Care surgery
• Pain neurosurgery
• Pediatric Neurosurgery
• Spine & Peripheral Nerves
• Stereotactic & Functional Surgery
• Tumor neurosurgery
• paranasal sinuses surgery
• functional endoscopic sinus surgery (FES) : endoscopic surgery of the paranasal sinuses to correct problems causing sinus infection.
• Caldwell-Luc operation : antrostomy in which an opening is made into the maxillary sinus by way of an incision into the supradental fossa opposite the premolar teeth, usually done to remove tooth roots or abnormal tissue from the sinus.  2. in compound zygomaticomaxillary fractures, the packing of the maxillary sinus by approaching the antrum through the canine fossa of the maxilla above the tooth apices, thus allowing reduction of displaced fragments of the zygoma by upward and outward pressure
• Killian's operation : excision of the anterior wall of the frontal sinus, removal of the diseased tissue, and formation of a permanent communication with the nose.
• Lynch's operation : incision of the frontal sinus and removal of its floor and contents; done in cases of expanding mucoceles, pyoceles, and tumors of the sinus.
• Ridell operation : obliteration of the frontal sinus by removal of the anterior wall and floor and sometimes posterior walls of the sinus; for treatment of malignant tumors.
• mastoidectomy : excision of the mastoid cells or the mastoid process of the temporal bone.
• tympanomastoidectomy : mastoidectomy with tympanectomy.
• closed-cavity tympanomastoidectomy / closed-cavity mastoidectomy / canal wall up tympanomastoidectomy or mastoidectomy / intact canal wall tympanomastoidectomy or mastoidectomy : tympanomastoidectomy with tympanoplasty and maintenance of an intact posterior wall of the ear canal
• open-cavity tympanomastoidectomy / open-cavity mastoidectomy / canal wall down tympanomastoidectomy or mastoidectomy : tympanomastoidectomy with removal of the posterior wall of the ear canal, such as radical mastoidectomy and modified radical mastoidectomy
• mastoid or mastoidectomy bowl : the hollow bony defect in the temporal bone created by open mastoidectomy
• simple mastoidectomy : mastoidectomy with exenteration of air cells but no involvement of the wall of the ear canal.
• cortical or complete simple mastoidectomy : mastoidectomy with exenteration of the air cells and epitympanum but no involvement of the wall of the ear canal
• radical mastoidectomy : mastoidectomy with exenteration of air cells, removal of the entire posterior wall of the ear canal, and removal of the tympanic membrane, malleus, and incus, resulting in permanent hearing loss.
• Bondy's modified radical mastoidectomy : mastoidectomy with exenteration of air cells and removal of part of the posterior wall of the ear canal but with preservation of some or all of the ossicles; hearing may be preserved.
• mastoidotomy : surgical incision of the mastoid process of the temporal bone, usually into the antrum.
• ear surgery : the surgical treatment of diseases of the ear
• cochleosacculotomy : creation of a fistula between the saccule and cochlear duct by means of a pick introduced through the round window, in order to relieve endolymphatic hydrops
• tympanolabyrinthopexy : Sourdille's operation of uniting a neotympanic system to a labyrinthine fistula for the cure of progressive hearing loss from otosclerosis; of historical interest.
• tympanostomy / tympanotomy / myringotomy : the creation of a hole in the tympanic membrane, as for tympanocentesis
• facial recess  or posterior tympanotomy : tympanotomy with exenteration of the air cells posterior to the facial recess
• tympanotomy : 1. tympanocentesis.  2. myringotomy.
• facial recess or posterior tympanotomy : tympanotomy with exenteration of the air cells posterior to the facial recess
• tympanectomy / myringectomy : excision of the tympanic membrane
• tympanoplasty : surgical reconstruction of the hearing mechanism of the middle ear, with restoration of the drum membrane to protect the round window from sound pressure, and establishment of ossicular continuity between the tympanic membrane and the oval window
• myringoplasty : surgical restoration of a perforated tympanic membrane by grafting
• myringostapediopexy : fixation of the pars tensa of the membrana tympani to the head of the stapes
• myringotomy / tympanostomy / tympanotomy : the creation of a hole in the tympanic membrane, as for tympanocentesis
• ossicular fixation : the fixing of one or more of the auditory ossicles by fibrous adhesion, tympanosclerosis, or bony fixation; it may be congenital or secondary to infection or trauma.
• ossiculectomy : surgical removal of an ossicle, or of the ossicles, of the ear.
• stapedectomy / platinectomy : excision of the stapes, a procedure introduced in 1960 by Shea
• posterior crus stapedectomy : a method based on the principal of renouncing a prosthesis by cutting the posterior crus of the stapes close to the footplate and the anterior crus close to the stapes head. METHODS: The posterior crus is temporarily transposed with the incudostapedial joint remaining intact. After performance of platinectomy and sealing of the oval window with fascia it is repositioned onto the center of the window. The major advantage of this technique is the avoidance of incus necrosis and foreign body reactions related to the material of the prosthesis. Disadvantages are technical plus the longer duration of the procedure^ref.
• stapediolysis / stapes mobilization : surgical correction of immobility of the stapes, in treatment of deafness resulting from otosclerosis
• stapedioplasty : stapedectomy followed by replacement with a prosthetic stapes, done to correct hearing loss due to otosclerosis
• stapediotenotomy : the cutting of the tendon of the stapedius muscle
• stapedotomy / platinotomy : the surgical creation of a small opening in the footplate of the stapes. It is a better technique than platinectomy because of the ease of execution and good functional results. The Jean-Bernard Causse technique of stapedotomy, derived from Jean Rene Causse "Teflon-interposition" technique, offers an optimum reconstitution of the function of the annular ligament of the stapes footplate. The quantity and quality of hearing depend significantly, among other things, on the function of the stapes footplate annular ligament. Its impedance keeps the perilymph motion within a physiological acoustic amplitude quantum level unless the movements are so excessive as in barotrauma and acoustic trauma which would have overworked even the annular ligament of a normal footplate. This surgical technique permits snorkling, scuba-diving, airplane landing, eustachian tube dysfunction after surgery as in a normal individual who did not undergo otosclerosis surgery^ref.
• large fenestra stapedotomy
• small fenestra stapedotomy
• platinostomy :
• platinofissure :
• SHC fenestration :
• labyrinthine trephination :
• ossiculotomy : surgical incision of the ossicles of the ear
• vestibulotomy : surgical opening of the vestibule of the inner ear.
• labyrinthectomy : excision of the labyrinth of the ear, done for implacable vestibular dysfunction when severe hearing loss is already present.
• transcanal labyrinthectomy : labyrinthectomy done through the auditory canals, with removal of the ossicles.
• transmastoid labyrinthectomy : labyrinthectomy done through the mastoid bone.
Areolar tissue is a loose conjunctive tissue, located between the fascia temporalis superficialis and the temporal aponeurosis. It can be used in several circumstances during otologic surgery. First, in stapes surgery, it can be used as an interposition between the piston and the platinotomy. Its thickness has no equivalent in comparison with other temporal tissues, explaining in part its usefulness in this indication. In perilymphatic fistula surgery, the areolar tissue is especially recommended for round window and oval window grafting because of its spontaneous adhesive capacity. It can be useful in myringoplasty, to reenforce an atrophic tympanic membrane or to close a small perforation. Also areolar tissue can be used as a flap or as a free graft to reconstruction of the external acoustic meatus. It's a good conjunctive support, which can be covered by skin graft. Finally areolar tissue is an interesting and useful material for otologic surgery. Its qualities are complementary to those of the temporal aponeurosis^ref.
• nasal truss : a trusslike support for fractured nasal bones
• dental or oral and maxillofacial surgery : that branch of dental practice that deals with the diagnosis and the surgical and adjunctive treatment of diseases, injuries, and defects of the human mouth and dental structures
• maxillotomy : surgical sectioning of the maxilla which allows movement of all or a part of the maxilla into the desired position
• dentofacial surgery : that branch of the healing arts which deals with the surgical and adjunctive treatment of diseases, injuries, and defects involving the face and structures of the mouth.
• root amputation / radiectomy / radisectomy : excision of the root of a tooth; amputation of the root of a single-rooted tooth is called apicoectomy, and that of one root of a 2-rooted mandibular tooth is hemisectomy
• apicoectomy / root resection : excision of the apical portion of a tooth through an opening made in the overlying labial, buccal, or palatal alveolar bone
• hemisectomy : amputation of one root of a two-rooted mandibular tooth
• teeth ligation : the binding together of teeth with wire, thread, or other material for their stabilization and immobilization as a method of tooth movement in orthodontic therapy or following traumatic injury.
• glossotomy : incision of the tongue
• vestibuloplasty : the surgical modification of the gingival–mucous membrane relationships in the vestibule of the mouth, including deepening of the vestibular trough, repositioning of the frenum or muscle attachments, and broadening of the zone of attached gingiva, after periodontal treatment.
• glossectomy / glossosteresis : partial or total surgical excision of the tongue
• hemiglossectomy : resection of one side of the tongue.
• Regnoli's operation : excision of the tongue through a median opening below the lower jaw, reaching from the chin to the hyoid bone.
Indications : tongue cancers
• glossoplasty : plastic surgery of the tongue
• glossorrhaphy : suture of the tongue.
• push-back procedure or technique : a surgical procedure designed to reposition the soft palate posteriorly and reestablish velopharyngeal competence
• mandibulectomy : surgical removal of the mandible
• sialoadenectomy : excision of a salivary gland.
• parotidectomy : excision of the parotid gland.
• sialoadenotomy : incision and drainage of a salivary gland.
• sialodochoplasty : surgical procedure for the repair of a defect and/or restoration of a portion of a salivary gland duct.
• sialolithotomy : surgical procedure by which a stone within a salivary gland or its duct is removed, either intraorally or extraorally.
• palatoplasty / uraniscoplasty / uranoplasty : plastic reconstruction of the palate
• palatorrhaphy / staphylorrhaphy / uraniscorrhaphy / uranorrhaphy : surgical correction of a cleft palate, the cleft involving the soft palate and the soft tissues over the hard palate
• orthognathic surgery : surgery to correct deformities of the jaw
• Fergusson's incision or operation : removal of the maxilla through an incision running along the junction of the nose with the cheek, around the ala of the nose to the median line, and then down to bisect the upper lip
• Sédillot's operation : a flap operation for restoring the upper lip.
• Stein operation : an operation for reconstruction of the lower lip with flaps taken from the upper lip.
• Abbe operation : attachment of a triangular, full-thickness flap from the median portion of the lower lip to fill a defect in the upper lip.
• Blair-Brown operation : repair of a cleft lip by the use of a lateral flap one-half the length of the lip.
• Logan bow : an appliance used to prevent tension on sutures after surgical repair of cleft lip.
• Estlander's operation : rotation of a triangular flap from the side of the lower lip to fill a defect in the lateral upper lip.
• Serre's operation : an operation for correction of skin contractures that distort the angle of the mouth, involving switching of a skin and subcutaneous tissue flap from one lip to another.
• Commando's operation : an operation for management of oral cancer, consisting in resection of the primary lesion and the regional lymphatic nodes.
• Partsch's operation : a technique for marsupialization of dental cyst.
• Sistrunk operation(1920) : a surgical procedure for removal of thyroglossal cysts and sinuses, consisting of removal of the central part of the hyoid bone, which in ontogenesis forms just after thyroid migration. 1-15% relapse
• pulp amputation / pulpotomy
• cusp restoration : restoration of the summit of a cusp or the incisal edge of a tooth, done for functional or cosmetic reasons.
• facial restoration : the replacement, usually with silver alloy, gold, or acrylic resin, of the facial portion of a posterior tooth lost through caries or injury.
• buccal restoration : the replacement, usually with silver alloy, gold, or plastic, of the buccal portion of a posterior tooth lost through caries or injury.
• prosthetic restoration : 1. the replacement of a lost or absent body part with an artificial structure, such as the use of an inlay, crown, bridge, or partial or complete denture, or other appliance to replace lost tooth structure, teeth, or oral tissue or structure.  2. any appliance, such as an inlay, crown, bridge, or partial or complete denture, used to replace lost tooth structure, teeth, or oral tissue or structure.
• periodontal surgery
• gingivectomy : surgical excision of the gingiva at the level of its attachment, thus creating new marginal gingiva; used to eliminate gingival or periodontal pockets or to provide an approach for extensive surgical interventions, and to gain access necessary to remove calculus within the pocket
• periodontal curettage
• gingival curettage : removal with a curet of the inflamed tissue wall of a periodontal pocket, including junctional and pocket epithelium and immediately underlying connective tissue
• apical or periapical curettage : removal with a curet of diseased pathological soft tissues in the bony crypt surrounding a tooth root apex and smoothing of the apical surface of a tooth without excision of the tooth tip
• subgingival curettage : gingival curettage apical to the epithelial attachment to sever the connective tissue attachment down to the osseous crest without reflection of a flap
• surgical curettage / modified Widman flap : a flap procedure to excise an inflamed periodontal pocket wall and the connective tissue attachment down to the osseous crest, followed by reattachment of the flap to the teeth
• ultrasonic curettage : removal of inflamed tissue from the tooth surface and wall of the gingival crevice with an ultrasonic scaler.
Web resources : American Association of Oral and Maxillofacial Surgeons (AAOMS)
• neck surgery
• thyroid surgery
• thyroidectomy / median strumectomy : surgical removal of the thyroid gland
• hemithyroidectomy : excision of one lobe of the thyroid gland.
• thyrocricotomy : incision of the cricothyroid membrane.
• thyroidotomy / thyrotomy : the operation of cutting the thyroid gland
• thyroparathyroidectomy : excision of the thyroid and parathyroids
• Anderson procedure : reconstruction of the hypopharynx and cervical esophagus by the use of bilateral rectangular flaps.
• strumectomy : surgical removal of a goiter.
• parathyroid surgery
• parathyroidectomy : excision of the parathyroid gland(s).
• radical neck dissection :  resection of a tumor in the neck along with an additional margin of at least 2 cm, as well as cervical lymphadenectomy.
• thoracic surgery
• thymectomy : surgical removal of the thymus gland. Indications : myasthenia gravis
• video-assisted thoracic surgery (VATS) / video thoracoscopic surgery : a less morbid alternative to "open" thoracotomy that employs cameras, optic systems, percutaneous stapling devices, and assorted endoscopic graspers, retractors, and forceps. It can be selectively applied to various pulmonary, pleural, and pericardial lesions.
• mediastinotomy : the operation of cutting into the mediastinum. Performed from the front, it is anterior or cervical mediastinotomy (Chamberlain technique : incision along parasternal line); from the back, posterior or dorsal mediastinotomy.
• Estlander's operation : resection of one or more ribs in empyema so as to allow the chest wall to collapse and close the abnormal cavity; of historical interest
• Freund's operation : resection of cartilages of the chest wall to restore elasticity and improve respiratory mechanics; of historical interest.
• Schede's operation : resection of the thorax for chronic empyema.  2. in cases of necrotic bone, excision of dead bone and diseased tissue, after which the cavity is permitted to fill with a blood clot that is kept moist and aseptic and eventually becomes organized.
• mastectomy : excision of the breast; mammectomy.
• conservative mastectomy in treatment of breast cancer with T < 3, usually associated with axillary lymphadenectomy.
• subcutaneous mastectomy : excision of breast tissue with preservation of overlying skin, nipple, and areola so that breast form may be reconstructed
• partial or segmental mastectomy : removal of only enough breast tissue to ensure that the margins of the resected surgical specimen are free of tumor
• quadrantectomy : a form of partial mastectomy involving en bloc excision of tumor in one quadrant of breast tissue, as well as the pectoralis major muscle fascia and overlying skin.
• wide excision
• tumorectomy / nodulectomy / lumpectomy / tylectomy : surgical excision of only the palpable lesion in carcinoma of the breast; called also .
• simple or total mastectomy : removal of only the breast tissue and nipple and a small portion of the overlying skin.
• radical Meyer or Halsted mastectomy : removal of the breast, both greater and smaller pectoral muscles, axillary lymph nodes (axillary lymph node dissection), and associated skin and subcutaneous tissue in treatment of breast cancer with T > 2 (Halsted William. Operations for carcinoma of the breast. J.Hopkins Hosp.Rep. 1:(2) 277-280 (1907)).
• extended radical mastectomy : radical mastectomy with removal of the ipsilateral half of the sternum and a portion of ribs 2 through 5 with the underlying pleura and the internal mammary lymph nodes.
• modified radical mastectomy : total mastectomy with axillary lymphadenectomy, but with preservation of the pectoral muscles.
• Patey mastectomy or operation : preservation of greater pectoral muscle (Patey DH & Dyson WH. The prognosis of carcinoma of the breast in relation to the type of operation performed. Brit.J.Cancer 2:7-13 (1948))
• Madden mastecomy : preservation of both pectoral muscles

Complications : homolateral upper limb lymphedema => lymphangiosarcoma
• cardiovascular surgery
• cardiac surgery : surgery of the heart.
• cardiotomy : surgical incision of the heart for repair of cardiac defects
• arterial switch procedure : a one-stage method for anatomical correction of transposition of the great vessels, in which both coronary arteries are transposed to the posterior artery, and the aorta and pulmonary arteries are transected, contraposed, and anastomosed.
• Jantene operation : a type of arterial switch procedure
• Glenn operation : an operation for congenital cyanotic heart disease, consisting of anastomosis of the superior vena cava to the right pulmonary artery.
• Blalock-Hanlon operation : a palliative operation for transposition of the great vessels, consisting of the creation of an interatrial septal defect.
• Blalock-Taussig operation : the side-to-side anastomosis of the left subclavian artery to the left pulmonary artery (sometimes the right subclavian to the right pulmonary artery) in order to shunt some of the systemic circulation into the pulmonary circulation; performed as palliative treatment of tetralogy of Fallot or other congenital anomalies associated with insufficient pulmonary arterial flow.
• Mustard operation : correction of transposition of the great vessels by construction of an intra-atrial baffle, composed of pericardial tissue or synthetic material, to direct the systemic and pulmonary venous blood into the left and right ventricles, respectively.
• Potts anastomosis, operation or shunt : anastomosis between the descending aorta and left pulmonary artery as palliative treatment of congenital pulmonary stenosis
• Rastelli operation : an operation for correction of large ventricular septal defects with pulmonary infundibular and valvular stenosis; an intraventricular patch is placed so that blood flows through the septal defect and out the aorta, and a prosthesis is placed to establish continuity between the right ventricle and the pulmonary artery.
• Senning operation : surgical creation of 2 interatrial channels for crossing the systemic and pulmonary venous circulations in transposition of the great vessels.
• Vineberg operation : implantation of the internal mammary artery into the myocardium to enhance the growth of collateral circulation.
• Waterston anastomosis, operation or shunt : anastomosis between the ascending aorta and right pulmonary artery as palliative treatment of congenital pulmonary stenosis
• endocardial resection procedure (ERP) : surgical removal of a portion of left ventricular endocardium and underlying myocardium containing an arrhythmogenic area (as determined by intraoperative cardiac mapping) from the base of an aneurysm or infarction; done to relieve ventricular tachycardia in patients with ischemic heart disease.
• extended endocardial resection procedure (EERP) : surgical removal of all visible endocardial fibrosis around the base of a left ventricular aneurysm; done to relieve ventricular tachycardia in patients with ischemic heart disease in whom intraoperative cardiac mapping is not possible.
• Fontan procedure : functional correction of tricuspid atresia by anastomosis of, or insertion of a nonvalved prosthesis between, the right atrium and the pulmonary artery with closure of the interatrial communication; it is also used in other selected congenital conditions.
• maze procedure : the surgical division of the normal conduction pathways between the sinoatrial node and the atrioventricular node by a series of incisions in the left atrium to create a maze of conduction pathways; its purpose is to allow a normal impulse to activate the atrium while eliminating macroreentrant circuits; done for the relief of atrial fibrillation.
• cardiolysis : an operation of freeing the heart and pericardium in adhesive mediastinopericarditis; it is done by resecting the ribs and the sternum over the pericardium
• pericardial decortication : asportation of parietal pericardium and adhesed thickenings
• pericardiectomy / pericardectomy : excision of the pericardium
• pericardiectomy : excision of the pericardium
• pericardiocentesis : surgical puncture of the pericardial cavity for the aspiration of fluid
• pericardiolysis : the operation of freeing adhesions between the visceral and parietal pericardium or between the pericardium and surrounding tissues or organs
• pericardiorrhaphy : the operation of suturing a wound in the pericardium.
• pericardiostomy : the creation of an opening into the pericardium, usually for the drainage of effusions.
• cardiopericardiopexy : the operative establishment of adhesive pericarditis; formerly used to increase blood flow to the heart.
• de-epicardialization : a surgical procedure formerly used for the relief of intractable angina pectoris, in which epicardial tissue is destroyed by phenolization or the application of other caustic agents to promote the development of collateral circulation.
• pericardiotomy / pericardotomy : surgical incision of the pericardium.
• decompression of heart or pericardium : pericardiotomy with evacuation of blood or fluid
Complications :
• postpericardiotomy syndrome
• postcardiotomy delirium, psychosis or syndrome
• open heart surgery : surgery that involves incision into one or more chambers of the heart.
• atriocommissuropexy : repair of the mitral valve with sutures passed from the ventricle through the valve leaflets and the atrial wall, for correction of mitral insufficiency.
• atrioseptopexy : a closed technique for surgical repair of a defect in the interatrial septum by suturing together part of the atrial wall to obstruct the defect
• atrial septectomy : surgical creation of a defect in the interatrial septum; performed to allow interatrial blood mixing in transposition of the great vessels
• Rashkind balloon atrial septostomy : surgical creation of an opening in the interatrial septum of the heart by passage of a balloon catheter from the right atrium through the septum to the left atrium, at which point the balloon is inflated and the catheter is then withdrawn to create an interatrial septal defect; performed in transposition of the great vessels with an intact septum.
• atrioseptoplasty : plastic repair of the interatrial septum
• atriotomy : surgical incision of an atrium of the heart.
• ventriculomyotomy : incision of the muscular wall of the heart.
• ventriculotomy : incision of a ventricle of the heart.
• partial encircling endocardial ventriculotomy : the encompassing and isolation of visible areas of endocardial fibrosis in the left ventricle by an incision extending part way through the endocardium; done to relieve ventricular tachycardia in patients with ischemic heart disease.
• valvuloplasty : plastic repair of a cardiac or venous valve.
• balloon valvuloplasty : dilation of a stenotic cardiac valve by means of a balloon-tipped catheter that is introduced into the valve and inflated.
• internal valvuloplasty : repair of a venous valve through a venotomy incision, using sutures to shorten the floppy cusps
• valvotomy / valvulotomy : incision of a valve
• mitral valvotomy : dilation of the left atrioventricular (mitral) valve, the commissures being split with or without the aid of a knife or a mechanical dilator.
• pulmonary valvotomy : incision of the pulmonary valve to correct valvular stenosis.
• Brock's operation / transventricular closed valvotomy : correction of pulmonary valvular stenosis by passage of a valvotome through the wall of the right ventricle into the pulmonary artery to open the valve
• cardiovalvulotomy : the operation of incising a cardiac valve, or of excising a portion of it, done for the relief of stenosis.
• cardiovalvulotome : an instrument for performing cardiovalvulotomy
• annuloplasty : plastic repair of a cardiac valve
• DeVega annuloplasty : a method for repair of an incompetent tricuspid valve by placing a series of purse-string sutures around the valve annulus to reduce it to the size of the obturator.
• Kay annuloplasty : a method for repairing a tricuspid valve with a dilated annulus but little prolapse: by placing several sutures at the commissures, the posterior leaflet is drawn forward toward the anterior leaflet and their surface area of approximation is increased
• minimally invasive heart surgery
• aorto-coronary by-pass (ACBP) / coronary artery bypass grafting (CABG) : a section of vein or other conduit grafted between the aorta and a coronary artery distal to an obstructive lesion in the latter. Vasilii I. Kolesov (1904-1992) is often referred to as the surgeon who performed the first successful CABG
• port access coronary artery bypass (PACAB) : the heart is stopped, and blood is pumped through an oxygenator bypass. Then, small incisions called “ports” are made in the chest and chest arteries or veins harvested from the patient's leg (femoral vessels) are attached to the heart, bypassing the clogged coronary artery or arteries. The surgeon passes instruments through the “ports” to perform these bypasses, viewing the procedures on video monitors.  Additional techniques are being perfected to replace damaged valves through similar “limited access ports.” Benefits include dramatic reduction in pain, reduced scarring, reduced ICU and hospital stay, accelerated recovery time, improved post-op pulmonary function and quality of life, plus a reduced need for inpatient cardiac rehabilitation.
• off-pump coronary artery bypass (OPCAB) : a modification of the conventional CABG, though much less invasive. The still uses an incision down the midline of the chest and sternum and retraction of the ribs for full access to the heart. This surgery does not, however, use the cardiopulmonary bypass pump because the “beating heart bypass” has had excellent short-term results as an effective and relatively inexpensive alternative to CABG.
• minimally invasive direct coronary artery bypass (MIDCAB) follows the basic premise of the conventional CABG procedure but in a minimally invasive fashion. The MIDCAB is performed on a beating heart without requirement of the heart-lung machine. Additionally, this procedure does not require splitting the sternum. Instead, a small 10 to12 cm incision in the chest or small holes and one incision are made directly over the coronary artery to be bypassed. Through these “ports,” the surgeon connects the graft to the diseased coronary arteries. However, because of the nature of this surgery, the MIDCAB procedure is only designed to bypass one or two coronary arteries. MIDCAB patients are required to remain in the hospital an average of two to three days after surgery. The conventional CABG requires an average post-op stay of five days. Because the MIDCAB incision is minimal, only certain patients — those with blockages of the left anterior descending artery or, occasionally, in the right anterior descending artery, are eligible. Those patients who are eligible for the MIDCAB procedure make up 35% of the total number of bypass surgeries each year. The new CABG requires only a 3-inch incision, which is significantly smaller than that of the conventional CABG procedure. The sternum is not split, and an artery that supplies blood to chest muscles is grafted to the left anterior artery. Benefits of this procedure include less pain and a shorter hospital stay of only two to four days instead of the conventional 7-10 days. Unfortunately, only about 10% of coronary artery disease patients are candidates for this procedure.
• totally endoscopic coronary artery bypass (TECAB)
Complications :
• fever increases likelihood of cognitive loss^ref
• aortitis
• mediastinitis
• pleural effusions : following CABG surgery, most patients will have a small unilateral left-sided pleural effusion, and approximately 10% of patients will have a larger effusion. They can be categorized by time intervals:
• perioperative (within the first week) effusions are usually attributable to diaphragm dysfunction or internal mammary artery harvesting and are typically self-limited
• early (within 1 month) effusions are usually attributable to postcardiac injury syndrome and may require corticosteroid treatment : they are bloody exudates with a high percentage of eosinophils
• late (2-12 months) effusions can have multiple causes and are clear yellow lymphocytic exudates.
• persistent (after 6 months) effusions are attributable to trapped lung and often require decortication
Diagnostic thoracentesis should be performed for patients with large symptomatic pleural effusions or fever after CABG surgery. The range of management includes observation, therapeutic thoracentesis, corticosteroids, or decortication depending on the cause and course of the effusion.

• heparin-induced thrombocytopenia :the  transient kinetics of the anti-PF4/H IgG response resembles neither that of recall Abs nor that of IgG autoantibodies, but rather shows a unique profile.
 Operatory risk : European System for Cardiac Operative Risk Evaluation
• age : 1 point every 5 years of fraction after age 60
• sex : 1 point if female
• chronic bronchopathy : 1 point if treated with bronchodilators or steroids
• arteriopathy : 2 points if carotid stenosis > 50% or previous or planned abdominal aorta surgery, limbs or carotids
• neuropathy : 2 points if severely impaired social life or deambulation
• reintervention : 3 points if a pericardiotomy has been already practiced
• creatininemia : 2 points if > 2.62 mg/dl (200 mol/l)
• endocarditis : 3 points if still under antibiotic therapy
• criticity : 3 points if ventricular tachycardia of fibrillation, resuscitation from sudden death, cardiac massage, mechanical ventilation, inotropic support, aortic contrapulsator, oligoanuria (< 10 ml/hr)
• angor : 2 points if at rest with nitrates in infusion
• ventricular function : 1 point if LVEF = 30-50%; 3 points if LVEF < 30%
• myocardial infarction : 2 points if occurred in the last 90 days
• pulmonary hypertension : 2 points if systolic pulmonary pressure > 60 mmHg
• emergence : 2 points if surgery is performed the day after presentation to the surgeon
• coronary bypass : 2 points if surgery different from or in adjunct to coronary bypass
• aorta : 2 points if surgery on thoracic aorta (ascending aorta, aortic arch or descending aorta)
• interventricular defect : 4 points if rupture of postinfarctual septum
0-2 points : mortality = 0,8%; 3-5 points : mortality = 3,0%; > 5 points : mortality = 11,2%
Web resources : Cardiac surgery in the adult
• vascular surgery : surgery of blood vessels
• arterial surgery
• endarterectomy : excision of the thickened, atheromatous tunica intima of an artery
• aortoiliac endarterectomy : one performed on the abdominal aorta and common iliac arteries, done for disease localized around their junctions.
• carotid endarterectomy (CEA) : endarterectomy of the carotid artery, done for the prevention of stroke.
• common femoral endarterectomy: one performed on the common femoral artery, done to relieve ischemia of the lower limb.
• gas endarterectomy : endarterectomy done with high-pressure CO₂ to remove plaque deposits from the coronary blood vessels in treatment of atherosclerosis.
• transluminal endarterectomy or atherectomy : that done using a cutting device inside a catheter that is inserted through the lumen of a vessel
• vertebral endarterectomy : endarterectomy of the vertebral artery, done to treat some types of vertebrobasilar insufficiency.
• thromboendarterectomy : removal of thrombus and atherosclerotic inner lining from an obstructed artery.
• atherectomy : the removal of atherosclerotic plaque from an artery using a rotary cutter inside a special catheter guided radiographically; it does not extend to the tunica intima as endarterectomy does.
• directional atherectomy : that done using a directional atherectomy catheter.
• rotational ablation or atherectomy / rotablation : an atherectomy technique in which a rotating bur is inserted through a catheter into an artery; the burr rotates and debulks atherosclerotic plaque.
• embolization / embolotherapy : therapeutic introduction of a substance into a vessel in order to occlude it in treatment of localized hemorrhages. It cannot be used in terminal vessels (to prevent ischemic necrosis) and very proximal vessels (to prevent massive embolization)
• embolectomy : surgical removal of an embolus, usually with Fogarty catheter
• Trendelenburg's operation : transthoracic pulmonary embolectomy.
• bypass : an auxiliary flow in the circulatory system
• partial bypass : the deviation of only a portion of blood flowing through an artery.
• carotid occlusion
• carotid-carotid bypass : insertion of a vascular prosthesis from the left carotid to the right carotid artery, serving as a passage around an occluded or stenosed portion of the brachiocephalic trunk.
• carotid-subclavian bypass : insertion of a vascular prosthesis from the subclavian artery to the common carotid artery as a passage around occluded or stenotic segments of either artery.
• extracranial/intracranial (EC/IC) bypass : anastomosis of the superficial temporal artery to a branch of the middle cerebral artery on the brain surface to improve collateral blood flow that has been reduced by occlusion or stenosis of the internal carotid or middle cerebral artery.
• cardiopulmonary bypass : diversion of the flow of blood to the heart directly to the aorta, via a pump oxygenator, avoiding both the heart and the lungs; a form of extracorporeal circulation used in heart surgery.
• aortoiliac occlusion
• aortofemoral bypass : insertion of a vascular prosthesis from the aorta to the femoral artery as a passage around atherosclerotic occlusions in the aorta and the iliac artery.
• aortobifemoral (ABF) bypass : aortofemoral bypass involving both femoral arteries.
• thoracic aortofemoral bypass : insertion of a vascular prosthesis from the thoracic aorta to the femoral artery, with femorofemoral bypass, as a passage around aortoiliac occlusion in patients in whom the abdominal aorta is unsuitable for grafting.
• aortoiliac bypass : insertion of a vascular prosthesis from the abdominal aorta to the iliac artery as a passage around intervening atherosclerotic segments.
• aortorenal bypass : insertion of a section of saphenous vein, hypogastric artery, or suitable substitute between the aorta and renal artery as a passage around occluded or stenotic segments.
• femorofemoral bypass : insertion of a vascular prosthesis between the femoral arteries as a passage around an occluded or injured iliac artery.
• aortosubclavian bypass : insertion of a vascular prosthesis from the aorta to a subclavian artery, serving as a passage around an occluded segment in or around their junction.
• axillary-axillary bypass : insertion of a vascular prosthesis between the axillary arteries, passing over the sternum, serving as a passage around occluded or stenosed segments.
• extra-anatomic bypass : an arterial bypass that does not follow the normal anatomic pathway, such as ...
• axillofemoral bypass : an extra-anatomic bypass consisting of a vascular prosthesis or section of saphenous vein extending from the axillary artery to the ipsilateral femoral artery to relieve lower limb ischemia in patients in whom normal anatomic placement of a graft is contraindicated, as by abdominal infection or aortic aneurysm.
• axillobifemoral bypass : an axillofemoral bypass combined with a femorofemoral bypass.
• axillopopliteal bypass : an extra-anatomic bypass consisting of a vascular prosthesis extending from the axillary artery to the popliteal artery to relieve lower limb ischemia in patients in whom the femoral artery is unsuitable for axillofemoral bypass.
• obturator (foramen) bypass
• hepatorenal bypass : insertion of a vascular prosthesis between the common hepatic artery and the renal artery, serving as a passage around an occluded segment in or near their junction.
• infrainguinal bypass : any of the bypass procedures connecting arteries of the lower limb, including femorofemoral, femoropopliteal, iliofemoral, and inframalleolar bypasses.
• femorofemoropopliteal bypass : insertion of a vascular prosthesis, or of a vascular prosthesis anastomosed to a section of saphenous vein, between the popliteal artery and the contralateral femoral artery as a passage around occluded, stenotic, or injured iliac and femoral arteries.
• femoropopliteal bypass : insertion of a vascular prosthesis from the femoral to the popliteal artery as a passage around occluded, narrowed, or injured segments.
• iliofemoral bypass : insertion of a vascular prosthesis from the iliac artery to the femoral artery, serving as a passage around an occluded or stenosed segment.
• obturator (foramen) bypass : an extra-anatomic type of iliofemoral bypass in which the graft passes through the obturator foramen; used when trauma or infection makes it necessary to avoid the femoral triangle.
• inframalleolar bypass : insertion of a vascular prosthesis in arteries of the foot to serve as a passage around an occluded or stenotic segment.
• infrapopliteal bypass : a bypass procedure connecting arteries below the knee.
• left heart bypass : diversion of the flow of blood from the pulmonary veins directly to the aorta, avoiding the left atrium and the left ventricle.
• right heart bypass : diversion of the flow of blood from the entrance of the right atrium directly to the pulmonary arteries, avoiding the right atrium and right ventricle.
• Eck's fistula : an artificial communication made between the end of the portal vein and the side of the inferior vena cava; used in animal experiments, and in humans for the treatment of esophageal varices in portal hypertension.
• Eck's fistula in reverse : an artificial communication created to route all the blood from the posterior (lower) part of the body through the portal vein and liver; used in animal experiments.
• end-to-side anastomosis : an anastomosis connecting the end of one vessel with the side of a larger one.
• end-to-end anastomosis : an anastomosis connecting the end of an artery and that of some other vessel, either directly or with a synthetic graft
• terminoterminal anastomosis : surgical anastomosis between the distal end of an artery and the proximal end of the corresponding vein and between the proximal end of the artery and the distal end of the vein.
• Hunter's operation : a former method of treating aneurysm, consisting of ligation of the artery on the proximal side of the aneurysm above the first collateral.
• aneurysmectomy : extirpation of an aneurysm by removal of the sac
• aneurysmoplasty : plastic reconstruction of an aneurysmal artery. Clamp abdominal aorta below renal arteries and above iliac bifurcation (if aneurysm is located above renal arteries extracorporeal circulation is required). As clamping causes tachycardia and increased cardiac output, eventual CHD or carotidopathies should be treated formerly to prevent hemorrhagic or ischemic strokes from carotid thrombosis. Identification of left renal vein and ligation of inferior mesenteric artery => suture of orifices of lumbar arteries => completation of posterior wall of aortic anastomosis => anterior aortorrhaphy
• Matas' operation / endoaneurysmorrhaphy : a formerly common type of aneurysmoplasty done by opening the aneurysmal sac and narrowing the internal lumen by suture
• aneurysmorrhaphy : the operation of suturing an aneurysm
• aneurysmotomy : the operation of incising the sac of an aneurysm
• arteriorrhaphy : suture of an artery
• arteriectomy : excision of a portion of an artery
• arterioplasty : surgical repair or reconstruction of an artery
• arteriotomy : incision of an artery.
• vein surgery
• phlebotomy / venepuncture / venesection / venipuncture / venisection / venotomy : incision of a vein, as for the letting of blood. 2. needle puncture of a vein for the drawing of blood
• phlebostasis / bloodless phlebotomy : temporary sequestration of a portion of the blood from the general circulation by application of tourniquets on an extremity
• femoral vein ligation to prevent pulmonary thrombembolism (PTE) from deep vein thrombosis (DVT). Complications : a high incidence of limb edema. Later, ligation of the IVC was performed, initially in patients harboring thrombi above the superficial femoral veins. Eventually, it replaced lower-level venous ligation. The operative mortality rate of 2-15% was not significantly different from that of femoral vein ligation, but a lower rate for recurrent PTE was reported. The optimal level of ligation was located immediately below the renal veins to prevent thrombosis due to venous stasis between the interrupted IVC and the renal veins. However, 10-16% of these patients had immediate lower-extremity swelling.
• Babcock's operation : a former method of treating varicose veins, consisting of excision using a long probe with an acorn tip.
• Trendelenburg's operation : an early method for treating varicose veins, consisting of ligation of the great saphenous vein
• vein stripping / saphenectomy : excision of a saphenous vein. Physicians disconnect and tie off all vein tributaries associated with the great saphenous vein through a small incision at the groin crease. Through the incision a stiff but flexible length of wire with an attached head is inserted into the vein. The wire is threaded through the vein and out an incision in the upper calf. The wire is pulled downwards, and the attached head travels through the vein, inverting it and pulling it away from each tributary vein. In this way, the length of vein is removed through the incision in the upper calf.
• stripper : a surgical instrument for excision of veins, consisting of a flexible stainless steel cable with a stripping cup or disk at one end and a guide tip at the other; a rigid type of external stripper is also utilized.
• Mayo's operation : a former method of treating varicose veins, consisting of removal with a long-handled stripper.

• phlebectomy : excision of a vein, or of a part of a vein
• transilluminated powered phlebectomy (TIPP) is a relatively new ambulatory phlebectomy procedure that uses an intense light to clearly see a person's superficial vein anatomy to pinpoint the location and extent of any varicose veins. The TIPP device allows doctors to suction out the length of the vein through one or two incisions. The procedure requires fewer microinsicions than small incision avulsion
• small incision avulsion : performed alone or in conjunction with vein stripping, small incision avulsion (vein removal) uses special hooks to pull the veins through many microincisions. The incisions are so small that they can be closed with adhesive strips.
• phlebophlebostomy / venovenostomy : operative anastomosis of vein to vein
• phlebophthalmotomy / ophthalmophlebotomy : phlebotomy to relieve congestion of the conjunctival veins
• phleboplasty : plastic operation for the repair of a vein.
• phleborrhaphy / venorrhaphy / venesuture / venisuture : the suturing of a vein
• arterialization : surgical alteration of a vein so that it functions as an artery.
• cardiovascular interventional radiology uses catheters 4-5 Ch-sized
• recanalization
• angioplasty : an angiographic (fluoroscopic) procedure for elimination of areas of narrowing in peripheral arteries in lower or upper limbs
• laser thermal angioplasty : the recanalization of an occluded artery by vaporizing the occlusion using laser energy delivered by a fiberoptic probe with a metal tip that converts light energy to heat energy.
• balloon angioplasty : angioplasty using a balloon-tip catheter that is inflated inside an artery, stretching the intima and leaving a ragged interior surface after deflation, which triggers a healing response and breaking up of plaque.


• percutaneous transluminal angioplasty : a type of balloon angioplasty in which the catheter is inserted through the skin and through the lumen of the vessel to the site of the narrowing
• percutaneous transluminal coronary angioplasty (PTCA) : percutaneous transluminal angioplasty to enlarge the lumen of a sclerotic coronary artery, an alternative to bypass cardiac surgery for selected patients with ischemic heart disease

The majority of patients undergoing surgical treatment for ST-elevation myocardial infarction receive antifibrinolytic therapy to limit blood loss. This approach appears counterintuitive to the accepted medical treatment of the same condition — namely, fibrinolysis to limit thrombosis. The association between aprotinin / bovine pancreatic trypsin inhibitor (BPTI) and serious end-organ damage indicates that continued use is not prudent. In contrast, the less expensive generic medications aminocaproic acid and tranexamic acid are safe alternatives^ref
• stents
• embolization
• pharmacotherapy
• local transcatheter fibrinolysis with fibrinolytic drugs

Indication : acute-subacute thrombotic ischemia (since 6-24 hours up to 2-3 weeks)
Complications :
• bleeding
• massive distal embolism
• endoprosthesis (stent-endograft) for aneurysms (endovascular aneurysm repari (EVRA))
• transjugular intrahepatic portosystemic shunt (TIPS)
• inferior vena cava filters
Web resources : The Premier Educational Resource for the Interventional Cardiology and Endovascular Medicine Community (TCTMD)
Laboratory examinations : thrombotic threshold velocity (TTV) : the minimum velocity of blood flow through a vascular graft or prosthesis below which thrombogenicity would begin along the intimal surface; variables affecting it include lumen diameter and type of material the graft or prosthesis is made of.
• respiratory surgery
• larynx surgery
• laryngectomy : surgical removal of the larynx
• hemilaryngectomy : excision of one lateral half of the larynx.
• laryngocentesis : surgical puncture of the larynx.
• laryngopharyngectomy : excision of the larynx and pharynx
• laryngoplasty : reconstruction of the larynx
• laryngorrhaphy : the operation of suturing the larynx
• laryngostomy : surgical creation of an artificial opening into the larynx
• cricoidectomy : excision of the cricoid cartilage.
• cricotomy : incision of the cricoid cartilage.
• cricotracheotomy : tracheotomy with incision of the cricoid cartilage.
• laryngotomy : surgical incision of the larynx.
• inferior laryngotomy / cricothyrotomy / cricothyroidotomy / intercricothyrotomy / thyrocricotomy : tracheotomy involving incision through the skin and cricothyroid membrane to secure a patent airway for emergency relief of upper airway obstruction. It is a life-saving procedure, which is in the final cannot-ventilate, cannot-intubate (CVCI) option in all airway algorithms, whether they concer prehospital, emergency rooom, intensive care unit or operating room patients.
• needle cricothryrotomy should be performed with catheters at least 4 cm in length and up to 14 cm in adults. The Jet Ventilator Catheter (VBM Medizintechnik GmbH, Sulz, Germany) is availabe in 3 sizes (babies, children and adults). The possibility of kinking of standard plastic catheters has led to the production of special 6F emergency transtracheal airway catheters (Cook Critical Care, Bloomington, IN).
• percutaneous crycothyrotomy involves using the Seldinger technique to gain access to the cricothyroid membrane (CTM), There are a number of commercial kits available. The Melker emergency cricothyrotomy catheter sets (Cook Critical Care, Bloomington, IN) are very user friendly and will soon be produced with a durable elastic, high volume, and low-pressure cuff in a 5 mm airway catheter. The Quicktrack (VBM Medizintechnik GmnH, Sulz, Germany) is available for children and adults, 2mm and 4mm I.D.s, respectively.
• surgical cricothyrotomy is perfomed by making incisions through the CTM using a scalpel, after which an ET is inserted. This is the most rapid technique and should beemployed when equipment for the less invasive techniques is unavailable and speed is of the essence
• median laryngotomy / laryngofissure / thyrofissure / thyrotomy : incision of the larynx through the thyroid cartilage
• subhyoid, superior or thyrohyoid laryngotomy : incision of the larynx through the thyrohyoid membrane
• laryngotracheotomy : incision of the larynx and trachea
• arytenoidectomy : surgical removal of an arytenoid cartilage
• King's operation / arytenoidopexy : surgical fixation of arytenoid cartilage or muscle
• cordectomy : excision of all or part of a vocal cord for cancers of vocal cords with mobile vocal cords
• external subperichondral partial laryngectomy : also internal perichondrium and thyroid cartilage are excised (for infiltrative tumors)
• internal subperichondral partial laryngectomy : only internal perichondrium is excised
• cordopexy : the operation of displacing outward the vocal cord for bilateral vocal cord paralysis.
• epiglottoplasty : plastic surgery of the epiglottis, such as trimming back its folds to correct laryngeal stridor in infants
• epiglottidectomy / epiglottectomy : excision of the epiglottis
• trachea surgery
• tracheostomy : creation of an opening in the anterior trachea for insertion of a tube to relieve upper airway obstruction and facilitate ventilation
• tracheofistulization : surgical creation of an opening in the trachea communicating with the cervical skin
• tracheoplasty : plastic repair of the trachea
• tracheorrhaphy : repair of an incised or wounded trachea.
• tracheotomy / tracheostomy : surgical creation of an opening into the trachea through the neck, with the tracheal mucosa being brought into continuity with the skin
• inferior or subisthmic tracheotomy : one below the isthmus of the thyroid.
• intermediate or transisthmic tracheotomy : one at the level of the isthmus of the thyroid
• superior or supraisthmic tracheotomy : one above the isthmus of the thyroid
• intercricothyroid tracheotomy is easier to practive but carries a greater risk of damaging vocal cords, hence is practiced only in cases of extreme urgency
It should not be left in place for > 50 minutes to prevent respiratory acidosis
• percutaneous dilatational tracheostomy (PDT) is the most commonly performed tracheostomy technique, yet it is still considered invasive and can cause trauma to the tracheal wall. The Ciaglia Blue Rhin™ (Cook Critical Care, Bloomington, IN) and PercuQuick^® (Rusch Inc., Duluth, GA) have a special coating which facilitate dilation of the trachea entrance site and allow controlled percutaneous introduction of tracheostomy tubes.
• translaryngeal tracheostomy (TLT) is a newer tracheostomy technique that is also considered to be a safe and cost-effective technique that can be performed at the bedside. It may be beneficial in patients who are coagulopathic
• Fantoni translaryngeal tracheostomy technique is a less invasive technique and has few complications as compared to the PDT technique because the stoma is performed outwards and the tracheal rings are simply divaricated
• modified Fantoni technique involves the use of a FOB in place of the rigid tracheoscope, the insertion of a J-shaped wire and the use of a small diameter RET positioned coaxially to the original airway, in order to ventilate the patient during introduction of the tracheostomy tube. This technique may be advantageous in those patients suffering from serious hypoxemia and considered difficult to intubate or have cervical spine injuries
• surgical tracheostomy is more invasive and should be performed in an elective manner and in a sterile environment
• lung surgery
• lung volume reduction surgery (LVRS) / reduction pneumoplasty : surgical removal of nonfunctional lung tissue in cases of advanced emphysema. It decreases the loss of elastic recoil and pulmonary hyperinflation.
• bullectomy : excision of a bulla, especially one of the giant ones seen in bullous emphysema in order to improve pulmonary function where giant bullae are compressing the functional lung tissue
• lobectomy : ablation of whole lobe
• pneumonectomy : ablation of whole lung
Assessment of pulmonary operative risk : contraindications
• P_{O2, artery} < 60 mmHg
• pulmonary arterial hypertension
• preoperative FEV₁ < 2 L (or 50% of predicted value)
• postoperative FEV₁ = preoperative FEV₁ ^. Q%_{remaining lung volume} < 0.8 L (or  40-50% of predicted value), high risk of chronic restrictive lung disease.
• pleura surgery
• thoracotomy / pleuracotomy / pleurotomy : surgical incision into the pleural space through the wall of the chest
• sternotomy : the operation of cutting through the sternum.
• median sternotomy : incision through the midline of the sternum, done to gain access to thoracic organs and other structures.
Anterior thoracotomy is practiced in trauma patients only for :
• direct contact defibrillation
• open field cardiac massage
• pericardiotomy (far away from phrenic nerve) in cardiac tamponade
• suture in massive hemothorax
Descending aorta is clumped preserving blood flow into coronary and carotid arteries
• thoracostomy : surgical creation of an opening in the wall of the chest for the purpose of drainage to treat hypertensive pneumothorax. When the patient is supine with extended arm, a toopical antiseptical is applied locally and a needle is inserted into the upper border of the rib lining the forth or fifth intercostal space (not lower as diaphragm is concave and there is risk to perforate abdominal cavity) along the line passing for nipples and a vertical line between anterior and mid-axillary lines) : a finger is then introduced to check location into pleural cavity.
• tube thoracostomy : thoracostomy with insertion of a chest tube at the level of the 2nd-3rd intecostal space for drainage of air or fluid from the pleural space. Drainage into water bell. Complications : reexpansion acute pulmonary edema^ref
• thoracoplasty : surgical removal of several ribs in order for the chest wall to move inward and collapse the lung; it was formerly a common method of collapse therapy and is still sometimes done to allow access during thoracic surgery.
• costoversion thoracoplasty : thoracoplasty in which several ribs are removed and replaced inside out in order to prevent outward movement of the chest wall.
• video-assisted thoracic or thoracoscopic surgery (VATS) : the use of a thoracoscope and other video assistive devices as well as instruments inserted through trocars for thoracic surgery; because of the smaller incisions, it has a lower morbidity rate than traditional open thoracic surgery
• artificial pleural symphysis or pleurodesis : the artificial production of adhesions between the parietal and the visceral pleura for treatment of persistent pneumothorax or severe pleural effusion; formerly done by physically irritating the pleural surface, it is now usually done with a chemical sclerosing agent.
• poudrage : the application of powder to a surface, as between the visceral and parietal layers of the pericardium or pleura to promote their fusion in pleurodesis.
• thoracoscopic talc poudrage : absolute peripheral blood lymphocyte count significantly decreased following thoracoscopic talc poudrage compared to baseline values (p=0.007). Similarly, peripheral blood CD3⁺, CD4⁺ and CD8⁺ lymphocyte counts significantly decreased compared to baseline (p=0.005, 0.02 and 0.03, respectively) with a more prominent reduction of CD3/CD45RO⁺ memory cells. No significant difference was found in the absolute number of CD19⁺, CD16⁺, CD56⁺, and CD57⁺ cells before and after thoracoscopic talc poudrage^ref.
Povidone–iodine pleurodesis with the use of 20 ml of 10% povidone–iodine is thought to be safe^ref. Some cases were associated with the use of Jodobac^ref, but all available povidone–iodine formulations contain sodium or potassium iodate as a stabilizer. The toxic effects of iodate on the retinal pigment epithelium are well established, and iodate is used frequently in animal models of retinal pigment epithelium damage^ref. The toxic effects of iodate on the retinal pigment epithelium have also been described in humans^ref. It has been proposed that toxic plasma levels are reached after ingestion of 10 mg of iodate per kilogram of body weight^ref. One analysis showed that 100 ml of Jodobac contains approximately 1.5 g of potassium iodate, which is enough to easily exceed the toxicity threshold. Other solutions, such as Braunol and Betaisadona, contain only approximately 150 mg of potassium or sodium iodate per 100 ml, but the association of their use with clinical manifestations is not known. At these concentrations, it is unlikely that the toxicity threshold can be reached with the applied amounts of povidone–iodine solutions.
• pleurectomy : excision of a portion of the pleura
• pleurolysis : surgical separation of pleural adhesions
• pleuroparietopexy : fixation of the visceral pleura to the parietal pleura, thus binding the lung to the chest wall
• pleuropneumonolysis : division of adhesions between the lung and the parietal pleura
• decortication of lung : removal of constricting visceral pleura to permit the lung to expand
• Abbe operation : attachment of a triangular, full-thickness flap from the median portion of the lower lip to fill a defect in the upper lip.
• esophagus surgery
• esophagectomy : excision of part (partial) or all (total) of the esophagus.
• transhiatal esophagectomy : removal of the thoracic part of the esophagus by blunt dissection superiorly through a cervical incision and inferiorly with a transhiatal approach through an abdominal incision
• Torek operation : an operation for the excision of the thoracic part of the esophagus; of historical interest.
• esophagomyotomy : incision through the muscular coat of the esophagus, the term usually referring to incision through the muscular coat of the distal part of the esophagus.
• esophagoplasty : a plastic operation on the esophagus.
• esophagoplication : the operation of narrowing the esophagus by folding in its wall.
• esophagocardiomyotomy / esophagogastromyotomy / Heller's cardiomyotomy, esophagomyotomy, myotomy, or operation : incision of the muscular coats of the esophagus and cardiac part of the stomach performed for relief of achalasia of the esophagus. The original procedure involved a myotomy on both anterior and posterior walls of the esophagus; in the currently used modification, only an extramucosal anterior myotomy is done
• Livaidatis' circular myotomy : in anastomosis of the upper and lower pouches for esophageal atresia, the lengthening of the upper pouch by circumferential esophagomyotomy
• esophagostomy : the creation of an opening into the esophagus.
• esophagocologastrostomy : surgical creation of a new connection between the esophagus and stomach, by interposition of a segment of colon.
• esophagocoloplasty : excision of a portion of the esophagus and its replacement by a segment of the colon.
• esophagoduodenostomy : surgical anastomosis between the esophagus and the duodenum
• esophagoenterostomy : surgical formation of an anastomosis between the esophagus and small intestine after total gastrectomy.
• esophagoesophagostomy : anastomosis between two parts of the esophagus.
• esophagofundopexy : surgical fixation of the fundus of the stomach to the esophagus.
• esophagogastrectomy : excision of the esophagus and stomach, usually the distal portion of the esophagus and the proximal stomach.
• esophagogastroanastomosis : surgical formation of an anastomosis between the esophagus and the stomach.
• esophagogastroplasty : plastic repair of the esophagus and stomach; cardioplasty.
• Grondahl-Finney operation : esophagogastroplasty in which the orifice between the esophagus and stomach is enlarged.
• esophagojejunogastrostomy / esophagojejunogastrostomosis :  the operation of mobilizing an isolated segment of jejunum and anastomosing its proximal end to the esophagus and its distal end to the stomach.
• esophagojejunoplasty : replacement of the esophagus with a segment of jejunum.
• esophagojejunostomy : surgical anastomosis between the esophagus and the jejunum.
• esophagolaryngectomy : en bloc excision of the upper cervical esophagus and larynx.
• Sugiura procedure : esophageal transection with paraesophageal devascularization and devascularization of the abdominal esophagus and proximal stomach; performed for the treatment of bleeding esophageal varices.
• Tanner's operation : an operation for bleeding esophageal varices in which the terminal end of the esophagus, the cardia, and the proximal portion of the stomach are freed of all external vascular and ligamentous connections, and the stomach is transected below the cardia.
Web resources : CTSNet : the cardiothoracic surgery network
• abdominal surgery : surgery of the abdominal viscera. The so-named difficult abdomen refers to previously operated abdomens or men with small pelvis during rectal resection
• laparotomy : surgical incision through the flank
• staging laparotomy : laparotomy for pathologic staging of subdiaphragmatic Hodgkin's disease. It always includes splenectomy, wedge and deep needle biopsies of liver lobes, and biopsies of multiple lymph nodes, and it may be accompanied by appendectomy and ovariopexy.
• lumbotomy : surgical incision through the loin

Side effects : lumbocele
• spleen surgery
• splenopexy : surgical fixation of a mobile spleen.
• splenorrhaphy : surgical repair of the spleen.
• splenotomy : surgical incision of the spleen.
• laparosplenotomy / splenolaparotomy : laparotomy to gain access to the spleen, usually for the purpose of draining a cyst or abscess of the spleen.
• splenocleisis : irritation of the surface of the spleen to induce the development of new fibrous tissue.
• splenectomy : excision or extirpation of the spleen. A median supraumbilical laparotomy is preferred to left subcostal incision as the former allows easier exploration of other eventually injured abdominal viscera, and expecially the liver, after mobilization, isolation, section, and ligation of vascular peduncle or clamping and en bloc resection (crash method). In babies and youngs a spleen autografts > 50% of initial splenic mass is performed in the greater epiploon to prevent postsplenectomy sepsis, but effectiveness is impaired by poor vascularization

Indications :
• splenomegaly
• splenic rutpure
• splenic tumor
• splenic abscess
• splenic infarction
• congenital hemolytic anemia : after age 5 to prevent OPSI (partial splenectomy is not effective)
• hereditary spherocytosis
• hereditary ellyptocytosis
• idiopathic and secondary autoimmune hemolytic anemia (AIHA) or severe thrombocytopenia (chronic idiopathic thrombocytopenic purpura) refractary to steroids
• chronic relapsing thrombotic thrombocytopenic purpura refractory to FFP transfusions and plasma-exchange
• thalassemias
• paroxysmal noctural hemoglobinuria : only if hypersplenism occurs
• palliative in chronic myeloproliferative and lymphoproliferative disorders :
• refractary or relapsing hairy cell leukemia
• staging and restaging laparosplenectomy in HD and NHL (in 50-80% in necroptic series, only in 1% in absence of lymphadenomegaly) has been replaced by CT/MRI/laparoscopy and anyway therapy for stage II/III/IV is now identical. It is now recommended only for diagnosis in stage IA nonbulky supradiaphragmatic agressive lymphomas (theoretically candidated to radiotherapy only, in which the finding of abdominal metastases requires addition of chemotherapy) and for therapy in splenic NHL (66% has pancytopenia and 82% experience improvements)
• myelofibrosis with splenic myeloid metaplasia (MMM) : only if severe persistent pain due to splenomegaly or splenic infarction, refractary hemolytic anemia, severe thrombocytopenia due to hypersplenism, or portal hypertension
• not in CML
• Felty's syndrome for patients with severe infections or associated AIHA => neutrophilia (80-90%; transient in 20-30%; mortality = 4.2%)
• Gaucher's disease or splenomegaly : partial splenectomy doesn't worsen bone disease and sepsis risk, but may present relapses of splenomegaly
• portal hypertension : only in splenic vein thrombosis and in true hypersplenism refractory to shunts. Splenectomy is no longer recommended as postsplenectomy thrombocytosis and surgery may induce vein thrombosis and increase esophageal varix bleeding. Fibrocongestive splenomegaly alone cannot cause liver injury and hypersplenism is usually mild and not corrected by splenectomy.
• Womack procedure : splenectomy with resection of the superior half of the greater curvature of the stomach, devascularization, and transgastric suturing of the varices; performed for variceal bleeding resulting from portal hypertension
Complications (25%, expecially in patients with hematological disorders or polytrauma) :
• left pleural effusion (rarely exudative pleuritis due to left subphrenic abscess)
• pulmonary atelectasis due to antalgic and traumatic diaphragmatic akinesia
• left bronchopneumonia or inferior lobar pneumonia due to atelectasis or microembolism
• acute pancreatitis or transient silent hyperamylasemia due to surgical trauma on pancreatic tail
• low-output pancreatic arterovenous fistula due to surgical trauma on pancreatic tail
• left supramesocolic abscess
• gastric or left colonic injuries due to direct intraoperatory traumas
• thrombocytosis (peak at postsurgery day 7-10, sometimes persisting for years) : asympatomatic or peripheral thrombophlebitis (expecially radicular or truncular pylephlebitis)
• overwhelming postsplenectomy infection (OPSI) or sepsis (4.5%)
• blood smear : target cells, Jolly bodies, transient neutrophilia, hemosiderin granules, thrombocytosis
• gastrointestinal surgery
• stomach surgery
• cardiectomy : excision of the cardiac portion of the stomach
• cardiotomy : incision into the cardiac end of the stomach or the cardiac orifice.
• gastroplication : the surgical treatment of gastric dilatation by stitching a fold in the stomach
• fundoplication / fundic wrapping : plication of the fundus of the stomach around the lower end of the esophagus, done as treatment for reflux esophagitis that may be associated with disorders such as hiatal hernia
• Belsey Mark IV fundoplication or operation : fundoplication for gastroesophageal reflux with the fundus being wrapped 270° around the circumference of the esophagus, leaving its posterior wall free; done through a thoracic incision
• Nissen fundoplication or operation : a type in which the fundus is wrapped completely around (360°)  the distal esophagus
• Toupet fundoplication or operation : a type in which the fundus is wrapped 180° to 200° around the distal esophagus; done for patients with poor esophageal clearance and asymmetrical extrinsic pressure
• Thal procedure : fundoplication of less than the entire circumference of the lower esophagus; done to correct a benign stricture or gastroesophageal reflux.
• gastrectomy / gastric resection : excision of
• total gastrectomy : excision of all the stomach
• gastroduodenectomy : excision of stomach and duodenum.
• subtotal or partial gastrectomy : excision of part of the stomach.
• hemigastrectomy : excision of half of the stomach.
• gastropylorectomy : excision of the pyloric portion of the stomach.
Complications :
• afferent loop syndrome
• dumping, jejunal, or postgastrectomy syndrome
• gastroplasty : plastic operation on the stomach
• gastric partitioning or stapling : a form of gastroplasty in which a small stomach pouch is formed whose filling signals satiety; used in treatment of morbid obesity
• horizontal gastroplasty
• Mason's vertical banded gastroplasty : the construction via EEA and TA suturers and Silastic bandellette of a small proximal pouch (25 mL) along the lesser curvature near the gastroesophageal junction, emptying through a narrow 1-cm outlet stoma into the distal stomach and duodenum; as it induces immediate satiety, it is used in the treatment of morbid obesity. When feeding despite satiety, vomiting may cause rupture of sutures. Nowadays a gastric band device is placed reversibly in laparoscopy
• laparoscopic adjustable gastric banding (LAGB / lap-band) : the placement of a band around the upper stomach. The band circumference size can be changed by percutaneously inflating or deflating a balloon in the band that is connected to a subcutaneous port and is commonly adjusted after surgery based on weight loss response and gastrointestinal symptoms. While this surgery is less complex, the results are somewhat less impressive than RYGB, and the effect of this procedure on gut endocrine factors is less explored. Removal of omental fat during gastric surgery for obesity may improve glucose homeostasis^ref, and future studies of this approach are warranted.
• Swedish adjustable gastric band (SAGB) (Ethicon Endosurgery, Johnson & Johnson, Dilbeek, Belgium) engineered as a low-pressure device^ref
Side effects : asymptomatic hyperinsulinemic hypoglycemia^ref
• gastroenteroplasty : a plastic operation on the stomach and small intestine.
• gastrotomy : incision into the stomach.
• gastroenterotomy : surgical incision into the stomach and intestine.
• gastrocolotomy : incision into the stomach and colon.
• gastromyotomy : incision through the muscular coats of the stomach down to the mucosa
• gastroenteroanastomosis : anastomosis between the stomach and small intestine in gastroenterostomy
• gastrolysis : surgical division of perigastric adhesions in order to mobilize the stomach
• gastropexy : surgical fixation of the stomach to prevent displacement.
• Hill posterior gastropexy : an operation for gastroesophageal reflux in which the reduced gastroesophageal junction is anchored by sutures between the proximal lesser curvature and the preaortic fascia, and sutures are placed in the crura to narrow the hiatus.
• gastrorrhaphy : suture of a wound of the stomach.
• gastrostomy : surgical creation of an artificial opening into the stomach; also, the opening so established.
• Ssabanejew-Frank operation : a method of performing gastrostomy by pulling a cone of the stomach through an incision in the left rectus muscle and suturing it to the skin.
• Kader's operation : gastrostomy by which the feeding tube is introduced through a valvelike flap which closes on withdrawal of the tube.
• Beck gastrostomy : creation of a permanent gastric fistula by the formation of a tube from the greater curvature of the stomach to the surface of the abdominal wall.
• Glassman gastrostomy : a permanent opening into the stomach created by forming a cone-shaped diverticulum from the anterior wall of the stomach.
• Janeway gastrostomy : creation of a permanent gastric fistula by the formation of a tube from the anterior gastric wall to the surface of the abdominal wall.
• Stamm gastrostomy : insertion of a tube into the gastric lumen, the tube exiting through a stab incision in the abdominal skin; the stomach is sutured to the peritoneum at the exit site.
• Witzel operation or gastrostomy : insertion of a tube into the gastric lumen, the tube being implanted so as to create a serosal tunnel of stomach as it enters the gastric lumen.
• gastroesophagostomy : surgical creation of an anastomosis between the stomach and the esophagus; done for stricture of the lower end of the esophagus.
• gastrogastrostomy / gastroanastomosis : surgical creation of an anastomosis between the pyloric and cardiac ends of the stomach, usually performed because of hourglass contraction of the middle third of the stomach; also, the anastomosis so established.
• gastroenterostomy : surgical creation of an artificial passage (anastomosis) between the stomach and intestines (usually the jejunum)
• Billroth gastrectomy or operation : partial resection of the stomach ...
• ... with isoperistaltic end-to-end anastomosis of the severed end of the duodenum to the end of the resected stomach (Billroth I). Gastroscopy is contraindicated.
• ... with side-to-side anastomosis of the resected stomach to the jejunum (Billroth II / Polya gastrectomy).
• gastroduodenostomy : surgical creation of an anastomosis between the stomach and the duodenum.
• gastroileostomy : surgical creation of an anastomosis between the stomach and ileum; also, the anastomosis so established
• gastrojejunoesophagostomy / esophagojejunogastrostomy
• gastrojejunostomy : surgical creation of an anastomosis between the stomach and jejunum; also, the anastomosis so established.
• Wölfler's operation : anterior gastrojejunostomy for pyloric obstruction; of historical interest.
• Mayo's operation : excision of the pyloric end of the stomach, followed by closure of both duodenum and stomach and the construction of an independent posterior gastrojejunostomy
• gastric bypass : gastrojejunostomy in which the stomach is transected high on the body, constructing of a small (about 20 mL) proximal gastric pouch, which empties into a segment of jejunum that is anastomosed end-to-side to the pouch as a Roux-en-Y limb (roux-en-Y gastric bypass (RYGBP)). It is used to treat severe obesity. Food immediately stimulates jejunocerebral negative feedback. A hole is practiced in mesocolon for passing the anastomosis. Food is not mixed with pancreatic juices. It can be perfomed laparoscopically (laparoscopic Roux-en-Y gastric bypass (LRYGBP)). Diabetes is rapidly ameliorated after RYGB and glycemic improvements often precede weight loss, supporting the view that changes in the gut hormonal milieu may be involved. An effect of surgery to increase PYY and GLP-1 levels has been reported^ref. A postoperative fall or a failure of ghrelin levels to rise after surgery, as it does after weight loss due to food restriction, has been observed^{ref1, ref2}, but proof that ghrelin suppression accounts for reduced appetite after RYGB awaits experiments in which ghrelin is replaced in such patients. Patients don't try to compensate for their smaller stomachs by eating more frequently;

Side effects : free of malabsorption after an initial phase of adjustment, dumping, jejunal, or postgastrectomy syndrome, hyposideremia, hypovitaminosis B₁₂ and D, hypocalcemia; hyperinsulinemic hypoglycemia and nesidioblastosis. The rapid presentation of nutrients in the duodenum stimulated excessive secretion of GLP-1, leading to islet-cell hypertrophy, proliferation, and neogenesis.
Complications : dumping, jejunal, or postgastrectomy syndrome
• gastrocolostomy : the creation of an artificial opening between the stomach and the colon; also, the opening so established.

• percutaneous endoscopic gastrostomy (PEG)
• gastrogavage : the introduction of nutriment into the stomach by means of a tube passed through the esophagus.
• gastrostogavage : introduction of nutriment into the stomach by means of a tube passed through a gastric fistula.
• gastrostolavage : irrigation of the stomach through a gastric fistula.
• pylorectomy : excision of the pylorus
• hemipylorectomy : excision of half of the pylorus.
• pylorogastrectomy : excision of the pylorus.
• pyloromyotomy / Fredet-Ramstedt operation: the operation for hypertrophic pyloric stenosis, performed by longitudinally incising the thickened serosa and muscularis down to the mucosa;
• pyloroplasty : incision of the pylorus and reconstruction of the pyloric channel to relieve pyloric obstruction or to accelerate gastric emptying after truncal or selective vagotomy in treatment of duodenal ulcer.
• double pyloroplasty : posterior pyloromyotomy combined with the Heineke-Mikulicz pyloroplasty.
• Finney's operation or pyloroplasty : reconstruction of the pyloric channel by means of a longitudinal incision through the pylorus and adjacent walls of the stomach and duodenum and the establishment of an inverted U -shaped anastomosis between the stomach and duodenum.
• Heineke-Mikulicz operation or pyloroplasty : reconstruction of the pyloric channel by incising the pylorus longitudinally and suturing the incision transversely
• Heidenhain pouch : a small pocket of the stomach which has been surgically separated from the body of the stomach, and thus vagally denervated, and which drains to the exterior; used in the experimental study of gastric physiology
• Pavlov pouch : a pocket of stomach which has been surgically separated from the body of the stomach by a mucosal septum, but which retains vagal innervation and muscular connection, and which drains to the exterior; used in the experimental study of gastric physiology
• liver surgery
• hepatectomy : excision of liver
• total hepatectomy : excision of all the liver
• partial or subtotal hepatectomy : excision of part of the liver.
• left hepatectomy : incision to left of middle hepatic vein => segments II, III, IVa, IVb removed
• extended left lobectomy : surgical removal of left liver and segments V and/or VIII
• right hepatectomy : incision line slightly to right of middle hepatic artery => segments V, VI, VII, and VIII removed
• extended right lobectomy : surgical removal of right liver and segment IV
• hepatic segmentectomy : surgical removal of a liver segment identified in vivo after vital staining with methylene blue
• bisegmentectomy : resection of 2 segments of the liver
• left lateral bisegmentectomy or segmentectomy : incision line at umbilical fissure => segments 2 and 3 removed


• trisegmentectomy : resection of the liver in which 3 segments are removed.
• left trisegmentectomy : that in which the left lobe and anterior segment of the right lobe are removed.
• right trisegmentectomy : incision line at umbilical fissue => the right lobe and medial segment of the left lobe are removed (segments IVa, IVb, V, VI, VII, and VIII).


• hemihepatectomy : excision of half of the liver.
• sectorectomy :
• mesohepatectomy : excision of segments IV, V, and VIII
Guidance : use of ultrasonic or radiofrequency scalpels and strict adhesion to segmental anatomy allows nonbleeding surgery (incision of suprahepatic veins could lead to gaseous embolism)
• intraoperative ultrasound to identify nonpalpable lesions and delineate vascular anatomy
• vascular occlusion techinques :
• Pringle maneuver : progressive, intermittent clamping of hepatoduodenal ligament. When continuous it should last < 20', while when intermittent (5 minutes of reflow after 15 minutes of no-flow) it can last hours
• digitoclaxia
• Kellyclaxia
During Pringle's maneuver there is continuous bleeding (run off) due to injury of suprahepatic vein (not clampable space) => supradiaphragmatic clamping
Complications :
• mortality for major liver resections has declined with improved operative techniques and postoperative care, but still significant. Operative mortality = 0-7%. The causes of death include
• hemorrhage
• sepsis
• liver failure
• morbidity of liver resection was 22-39%, and the causes of morbidity included
• hemorrhage
• biliary leak or fistula
• liver failure
• abscess around liver
• wound infection
• pneumonia.
• thrombophlebitis => pulmonary embolism
• hepatotomy : surgical incision of the liver.
• transthoracic hepatotomy : incision of the liver by resecting a rib, opening the pleural sac, and incising the diaphragm; often performed in 2 or 3 stages.
• hepaticodochotomy : surgical incision of the hepatic duct and the common bile duct.
• hepaticostomy : surgical creation of an artificial opening into the hepatic duct.
• hepaticocholangiojejunostomy : surgical creation of a communication between the hepatic duct, another biliary duct, and the jejunum.
• hepaticocholedochostomy : surgical anastomosis of the hepatic duct and the common bile duct.
• hepaticoduodenostomy : surgical creation of a communication between the hepatic duct and the duodenum.
• hepaticoenterostomy : surgical creation of a communication between the hepatic duct and the intestine.
• hepaticogastrostomy : surgical creation of a communication between the hepatic duct and the stomach.
• hepaticojejunostomy : surgical creation of a communication between the hepatic duct and the jejunum.
• hepatostomy : surgical creation of an opening into the liver.
• hepatoenterostomy : surgical creation of a communication between the liver and the intestine
• hepatoduodenostomy : the surgical creation of a communication between the liver and the duodenum.
• hepatocholangiostomy : the operation of establishing drainage of the hepatic duct either through the abdominal wall (external hepatocholangiostomy) or into some part of the gastrointestinal tract (internal hepatocholangiostomy).
• hepatocholangioduodenostomy : the operation of establishing drainage of the hepatic duct into the duodenum.
• hepatocholangioenterostomy : surgical creation of a communication between the hepatic duct and the intestine.
• hepatocholangiogastrostomy : the operation of establishing drainage of the hepatic duct into the stomach.
• hepatoportoenterostomy / portoenterostomy / portojejunostomy / hepatic or Kasai's portoenterostomy (KHES) / Kasai operation : surgical anastomosis of the jejunum to an intrahepatic biliary radicle; done to establish a conduit from the intrahepatic bile ducts to the intestine in biliary atresia or stenosis or common duct tumor
• hepaticolithotomy : incision of the hepatic duct and removal of one or more calculi.
• hepatolithectomy : removal of a calculus from the liver.
• hepaticolithotripsy : the operation of crushing a stone in the hepatic duct.
• hepaticotomy : incision of the hepatic duct.
• hepatopexy : surgical fixation of the displaced liver.
• hepatorrhaphy : operative repair of the liver.
• portosystemic shunt or anastomosis : a surgically created shunt that connects the portal and systemic circulations, such as a mesocaval, portacaval, or splenorenal shunt for treatment of portal hypertension
• portacaval shunt : a portosystemic shunt between the portal vein and lower vena cava
• splenorenal shunt / Linton shunt : removal of the spleen with anastomosis of the splenic vein (which inverts blood flow direction) to the left renal vein; done for the treatment of esophageal varices
• distal splenorenal shunt (DSRS) / Warren shunt : anastomosis of the distal splenic vein to the inferior vena cava with preservation of the spleen; done for the treatment of esophageal varices

• transjugular intrahepatic portosystemic shunt (TIPS)
• LeVeen peritoneovenous shunt : a surgically implanted subcutaneous plastic tube for continuous shunting of ascites fluid from the peritoneal cavity to the jugular vein; a pressure-activated valve buried in the abdominal wall ensures one-way flow.
• lumboperitoneal shunt : a communication between the lumbar subarachnoid space and the peritoneum by means of a plastic tube with an in-line pressure-flow regulator; created to permit drainage of cerebrospinal fluid for relief of communicating hydrocephalus.
• gallbladder surgery
• cholecystectomy : surgical removal of the gallbladder.

Indications :
• cholelithiasis accompanied by biliary colic, acute cholecystitis, calcifications of gallbladder or acute pancreatitic without other obvious cause
• gallbladder adenocarcinoma
Complications : postcholecystectomy syndrome
• cholecystenterorrhaphy : suture of the gallbladder to the small intestine.
• cholecystocolotomy : surgical incision of the gallbladder and colon
• cholecystostomy
• cholecystoduodenostomy / duodenocholecystostomy / duodenocystostomy : surgical anastomosis of the gallbladder and the duodenum
• cholecystogastrostomy : surgical anastomosis between the gallbladder and the stomach.
• cholecystenterostomy / cholecystenteroanastomosis / enterocholecystostomy : surgical anastomosis of the gallbladder to the intestine
• cholecystoileostomy : surgical anastomosis of the gallbladder and the ileum.
• cholecystojejunostomy : surgical anastomosis of the gallbladder and the jejunum.

Indications : palliation of cholangiocarcinoma
• cholecystocolostomy / colocholecystostomy : surgical anastomosis of the gallbladder to the colon
• cholecystolithotripsy : the fragmentation of gallstones within the gallbladder
• cholecystopexy : suspension or fixation of the gallbladder by surgical means
• cholecystopyelostomy / cholecystonephrostomy : surgical anastomosis of the gallbladder to the pelvis of the kidney
• cholecystorrhaphy : suture or repair of the gallbladder.
• cholecystotomy : surgical incision of the gallbladder; done for exploration, drainage (cholecystostomy), or removal of calculi.
• biliary tract surgery
• choledochectomy : excision of a portion of the common bile duct.
• choledochocholedochostomy : surgical formation of an anastomosis between two portions of the common bile duct.
• choledochoduodenostomy : surgical anastomosis of the common bile duct to the duodenum.
• choledochoenterostomy : surgical anastomosis of the common bile duct to the intestine.
• choledochogastrostomy : surgical anastomosis of the common bile duct and the stomach.
• choledochohepatostomy : surgical anastomosis of the common bile duct to the hepatic duct.
• choledochoileostomy : surgical anastomosis of the common bile duct and the ileum.
• choledochojejunostomy : surgical anastomosis of the common bile duct and the jejunum.

Indications : palliation of cholangiocarcinoma
• choledocholithotomy : incision of the common bile duct for the removal of stone.
• choledocholithotripsy : the crushing of a gallstone within the common bile duct.
• choledochoplasty : the performance of a plastic operation on the common bile duct; plastic repair of the duct following injury.
• choledochorrhaphy : suture or repair of the common bile duct.
• choledochostomy : surgical formation of an opening into the common bile duct and drainage by catheter or T -tube.
• choledochotomy / choledochendysis : incision into the common bile duct for exploration or removal of a calculus
• cholelithotomy : removal of gallstones through an incision in the gallbladder.
• cholelithotripsy / cholelithotrity : the crushing of gallstones.
• biliary stent
• biliointestinal bypass was introduced in 1975, entailing anastomosis of the blind jejunal loop to a functioning gallbladder to eliminate the blind loop in conventional jejunoileal bypass (JIB) and to maintain enterohepatic circulation of bile, thus hoping to diminish important side-effects of JIB. Jejunoileal bypass combined with cholecystojejunostomy in patients with functioning gallbladders is a safe and relatively simple method for treating morbid obesity in selected cases^ref. Recommended for patients with super-obesity (BMI > 50 kg/m_BSA²)
• papillosphincterotomy : surgical division of the sphincter of the major duodenal papilla (Oddi's sphincter)
• papillotomy : incision of a papilla, as of the duodenal papilla.
• papillotome : a cutting instrument for incising the major duodenal papilla.
• pancreas surgery
• pancreaticogastrostomy : surgical anastomosis of the pancreatic duct, or the divided end of the transected pancreas, with the stomach.
• pancreaticoenterostomy / pancreatoenterostomy : surgical anastomosis of the pancreatic duct, or the divided end of the transected pancreas, with the intestine.
• pancreaticoduodenostomy (PD) / pancreatoduodenostomy : surgical anastomosis of the pancreatic duct, or the divided end of the transected pancreas, with the duodenum.
• pancreaticojejunostomy : surgical anastomosis of the pancreatic duct, or the divided end of the transected pancreas, with the jejunum.
• pancreatectomy / pancreectomy : surgical removal of the pancreas.
• pancreatoduodenectomy / duodenocephalopancreatectomy : excision of the head of the pancreas along with the encircling loop of the duodenum.
• Whipple procedure (Whipple Alan O., Parsons WB & Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann.Surg. 102:763 (1935)) : radical pancreatoduodenectomy with removal of the distal third of the stomach, the entire duodenum, and the head of the pancreas, with gastrojejunostomy, choledochojejunostomy, and pancreaticojejunostomy.
• Brunschwig's operation : a technique of pancreatoduodenectomy.
• pancreatolithectomy : removal of a calculus from the pancreas.
• pancreatolithotomy / pancreolithotomy : incision of the pancreas for the removal of a calculus.
• pancreatomy / pancreatotomy : incision of the pancreas.
• pancreatobiliary bypass / biliopancreatic diversion : introduced by Scopinaro in 1979. Creation of a 200- to 500-mL proximal gastric pouch + the creation of a 200- to 500-mL proximal gastric pouch and transsection of the small intestine 250 cm from the ileocecal valve; the distal end of the small intestine is anastomosed to the gastric pouch and the proximal limb anastomosed to the ileum 50 cm from the ileocecal valve. These anastomoses create a 200-cm “alimentary tract,” a variable length (300 to 500 cm) “biliary tract,” and a 50-cm “common tract” in which digestion and absorption of ingested food occur. The biliopancreatic diversion with duodenal switch procedure involves the removal of  about 60% of thegreater curvature of the stomach and transection of the proximal duodenum (2/3 gastrectomy (once commonly used to treat duodenal ulcers, nowadays used only for bleeding ulcers or gastrostenosis)) + cholecystectomy (as gastrectomy leads to cholelithiasis). The proximal portion of the duodenum is anastomosed end-to-end to the distal small intestine 250 cm proximal to the ileocecal valve. The distal end of the resected proximal intestine, which receives secreted pancreatic enzymes, is anastomosed to the ileum 100 cm proximal to the ileocecal valve. This avoid bacterial overgrowth in the bypassed small bowel seen in jejunoileal bypass

Side effects : selective lipid malabsorption => malodorant steatorrhea. Soon after surgery the patient should be forced to eat protein-based meals. Hepatic complications are less common but PEM may lead to ascitis and require TPN. Fat-soluble vitamin deficiencies are common
• intestinal anastomosis : the establishment of a communication between 2 portions of the intestinal tract.
• Braun's anastomosis : formation of an anastomosis between the afferent and efferent intestinal loops just distal to a gastroenteric stoma to prevent vicious cycling of gastric and duodenal contents.
• end-to-end anastomosis : anastomosis of 2 sections of colon, such as with partial colectomy or when an ileostomy is closed.
• ileorectal anastomosis :  surgical anastomosis of the ileum and rectum after total colectomy, as is often done in treatment of ulcerative colitis.
• Roux-en- Y anastomosis : any Y-shaped anastomosis in which the small intestine is included; after division of the small intestine segment, the distal end is implanted into another organ, such as the stomach or esophagus, and the proximal end into the small intestine below the anastomosis to provide drainage without reflux.
• Jaboulay button : a device for performing lateral intestinal anastomosis without the aid of sutures, consisting of 2 buttonlike cylinders of metal that are fitted together on the screw and key-ring principle through a small intestinal opening.
• Murphy's button : a device for joining the ends of a divided intestine so that union may take place. It consists of 2 short metal cylinders of different diameter, each having a collar at one end; the collars are sutured to the divided ends, and the narrower cylinder is locked into its mate.
• small bowel surgery
• intestinal bypass : resection of the intestine, with anastomosis of the proximal to the distal portion, as in jejunoileostomy.
• enterectomy : excision of a part of the intestine; resection of the intestine.
• Mikulicz's operation : enterectomy in stages, including exteriorization of the section of intestine to be resected, usually the colon; resection of the exteriorized loop; elimination of the fecal fistula by crushing the spur between the 2 barrels of the anastomosis; and closure of the fecal fistula.
Complications : short-bowel or short-gut syndrome
• enterocentesis : surgical puncture of the intestine.
• enterocholecystotomy : incision into the gallbladder and the intestine.
• enterocleisis : closure of a wound in the intestine
• omental enterocleisis : closure of an intestinal perforation by suturing the omentum over the defect.
• enterocolectomy : resection of the intestines, including the ileum, cecum, and ascending colon.
• enterocolostomy : the surgical formation of a communication between the small intestine and the colon; also, the opening so constructed.
• enteroenterostomy / enteroanastomosis : surgical anastomosis between two segments of the intestine
• enterolysis : the operative division of adhesions between loops of intestine or between the intestine and abdominal wall.
• enteropexy : surgical fixation of the intestine to the anterior or posterior abdominal wall, or occasionally of one segment to another.
• enteroplasty : plastic surgery of the intestine, especially to enlarge the caliber of a constricted segment or area of bowel
• strictureplasty : surgical enlargement of the caliber of a constricted bowel segment by means of longitudinal incision and transverse suturing of the stricture.
• enterorrhaphy : repair or suture of the intestine.
• circular enterorrhaphy : the suturing of two completely divided portions of intestine after invaginating one segment over the other so that they are joined end to end.
• enterostomy : the formation of a permanent opening into the intestine through the abdominal wall, usually by surgical means; also, the opening so created.
• gun-barrel enterostomy : enterostomy in which the 2 segments of the divided intestine are parallel to one another as they emerge through the abdominal wall, like the tubes of a double-barreled shotgun.
• antiperistaltic anastomosis : enterostomy in which the intestinal segments are so joined that the directions of the peristaltic waves in the 2 conjoined portions are opposed.
• isoperistaltic anastomosis : enterostomy in which the intestinal segments are so joined that the peristaltic waves in the 2 conjoined portions progress in the same direction.
• enterotomy : incision into the intestine
• duodenotomy : incision of the duodenum.
• duodenectomy : excision of the duodenum, total or partial
• duodenocholedochotomy : surgical incision of the duodenum and common bile duct.
• duodenostomy : surgical formation of a permanent orifice into the duodenum.
• duodenoenterostomy : surgical formation of a communication from the duodenum to another part of the small intestine
• duodenoduodenostomy : anastomosis of the 2 portions of a divided duodenum.
• duodenoileostomy : surgical formation of a communication between the duodenum and the ileum.
• duodenojejunostomy : surgical formation of a communication between the duodenum and the jejunum.
• cystoduodenostomy : internal drainage of an adjacent cyst into the duodenum
• duodenolysis : the operation of loosening the duodenum from adhesions.
• duodenopancreatectomy : pancreatoduodenectomy.
• duodenorrhaphy : the operation of suturing the duodenum.
• jejunectomy : excision of the jejunum.
• jejunorrhaphy : operative repair of the jejunum.
• jejunostomy : the surgical creation of a permanent opening between the jejunum and the surface of the abdominal wall; also, the opening so established.
• jejunocecostomy : the formation of an anastomosis between the jejunum and cecum; also, the anastomosis so formed.
• jejunocolostomy : the formation of an anastomosis between the jejunum and the colon; also, the anastomosis so formed.
• jejunoileostomy : the formation of an anastomosis between the proximal jejunum and the terminal ileum; also, the anastomosis so formed.
• jejunojejunostomy : the operative formation of an anastomosis between 2 portions of the jejunum; also, the anastomosis so formed.
• jejunotomy : surgical incision of the jejunum.
• jejunal or jejunoileal bypass : surgical anastomosis of the proximal part of the jejunum (14 in. of ileum) to the distal part of the ileum (4 in. from caecum) so as to circumvent much of the small intestine and reduce intestinal absorption, used to treat obesity

Complications :
• malabsorption
• nephrolithiasis
• bowel bypass syndrome
• D-lactate acidosis
• fatty liver => hepatic failure
• chronic diarrhea => hemorrhoids, rhagades, and rectal fistulas
• partial ileal bypass : anastomosis of the proximal end of the transected ileum to the cecum, the bypass of the portion of the small intestine resulting in decreased intestinal absorption of and increased fecal excretion of cholesterol; sometimes used in treatment of hyperlipidemia and in weight reduction.
• ileectomy : surgical removal of the ileum.
• ileocecocystoplasty : cystoplasty in which a segment of ileum and cecum is used to reconstruct or augment the bladder.
• ileotomy : incision of the ileum.
• ileocolotomy : surgical incision of the ileum and colon.
• ileocystoplasty : cystoplasty incorporating an isolated loop of the ileum as part of the bladder wall.
• ileorrhaphy : operative repair of the ileum.
• ileoanal anastomosis : anastomosis of the terminal ileum and anus following colectomy, often in conjunction with creation of an ileoanal reservoir; performed in the management of ulcerative colitis
• ileoanal reservoir : a pouch for the retention of feces, formed by suturing together multiple limbs of ileum and connected to the anus by a short conduit of ileum; done in conjunction with colectomy and ileoanal anastomosisto provide for continent elimination of feces in the management of ulcerative colitis
• J pouch : an ileoanal reservoir created by lateral anastomosis of 2 loops of ileum 15 to 20 cm long.
• S pouch : an ileoanal reservoir created by lateral anastomosis of 3 sections of ileum each 10 to 15 cm long in a configuration resembling the letter S .
Side effects : pouchitis (23% and 18% in 2 metanalysis involving 9200 patients^ref (Lehrmann J, Stucchi AF, LaMorte WW, et al. Complications and outcomes after ileal pouch–anal anastomosis (IPAA): a meta-analysis of more than 8300 patients. Gastroenterology 2003;124:A814-A814) and pouch failure (5% and 6.8%). In another series of > 750 patients in whom the procedure was performed by a single surgeon (Dr. Becker), acute pouchitis occurred in 12%, chronic pouchitis in 10%, and pouch failure in 2%^ref. Other studies of the cumulative frequency of pouchitis, adjusted for time since colectomy, report pouchitis in 40 to 50% of patients within 5 years after colectomy, a rate similar to those reported by Hahnloser et al. of 38% within 10 years and 47% within 15 years after surgery^{ref1, ref2}. Within 10 years after surgery, 53% of patients require one or more reoperations for postoperative complications, and 10% of patients require pouch excision by 10 years. Nocturnal fecal incontinence in patients who have an ileoanal pouch is, indeed, an "inconvenience" that is reminiscent of their presurgery symptoms of colitis (but without the debilitating disease). However, the overall prevalence as 24%^ref. Their data actually show that the proportion of patients with more than two episodes of nocturnal staining per week was 5%. The proportion increased to 24% only after 15 years, by which time the population had aged to a mean of 50 years and included patients up to 77 years of age. This increase mainly reflected postpartum and senescent decline in sphincter strength^{ref1, ref2, ref3} .
• continent ileal reservoir : an intra-abdominal pouch having a volume of at least 500 mL and a valve; it maintains continence of feces and is emptied by a catheter when full
• Kock pouch : the most common kind of continent ileal reservoir, with a capacity of 500 to 1000 mL and a valve made by intussusception of the terminal ileum.
• ileostomy : surgical creation of an opening into the ileum, usually by establishing an ileal stoma on the abdominal wall.
• continent ileostomy : an ileostomy that maintains continence of feces, usually through construction of a continent ileal reservoir; now largely replaced by ileoanal anastomosis procedures.
• Kock ileostomy or procedure : the most common type of continent ileostomy, having a Kock pouch; now mostly of historic interest.
• ileoileostomy : surgical creation of an opening between two parts of the ileum; also, the opening so established.
• ileocystostomy : surgical creation of an opening between the urinary bladder and ileum.
• ileocecostomy / cecoileostomy  : surgical creation of an opening between the ileum and the cecum; also, the opening so established.
• ileocolostomy : surgical creation of an opening between the ileum and colon; also, the opening so established.
• ileotransversostomy : surgical creation of an opening between the ileum and the transverse colon.
• ileosigmoidostomy : surgical creation of an opening between the ileum and the sigmoid colon.  2. the opening created by such a procedure.
• ileoproctostomy / ileorectostomy : anastomosis of the ileum and rectum.
ileostomy bag : any of various plastic or latex bags for the collection of urine or fecal material following ileostomy or the establishment of an ileal bladder; a flange or similar device fits closely about the ileal stoma and the bag is cemented to the skin or strapped to the body.
• Perry bag : an ileostomy bag with a small latex cuff reinforced by a plastic disk which fits snugly around a protruding stoma; the cuff is held down by a large plastic ring to which a belt is attached.
• Whitmore bag : an ileostomy bag with a malleable flange and a valvular device for urine drainage at the lower end of the bag.
The continence of intestinal anastomoses is assessed by filling the bowel with air and the peritoneal cavity with water at the end of surgery.
• large bowel surgery
• mucosectomy : excision of the tunica mucosa, such as in the colon in the treatment of inflammatory bowel disease (IBD)
• Amussat's operation : a long transverse incision for exposure of the colon.
• typhlopexy : operative suspension and fixation of the cecum.
• cecopexy / cecofixation : fixation or suspension of the cecum to correct excessive mobility of the organ
• cecocolopexy : an operation for fixing the cecum and ascending colon to the abdominal wall.
• cecoplication : plication of the cecal wall to correct ptosis or dilatation of the organ.
• cecectomy : surgical removal of the cecum
• cecotomy : the operation of cutting into the cecum.
• cecorrhaphy : suture or repair of the cecum.
• cecostomy : the surgical creation of an artificial opening or fistula into the cecum; also, the opening so constructed.
• cecosigmoidostomy : formation of an artificial opening between the cecum and sigmoid, usually by surgical procedure; also, the opening so constructed.
• appendicectomy / appendectomy : surgical removal of the vermiform appendix.
• colotomy : incision into the colon for removal of a foreign body, polyp, or other benign tumor.
• lumbocolotomy : an incision into the colon through the loin.
• colostomy : the surgical creation of an opening between the colon and the surface of the body; also used to refer to the opening, or stoma, so created. Semicontinuous suture reduces risks of deiscence and/or filtration of stools better than separated (2 anterior and 2 posterior) muco-mucous sutures. The patient is reeducated to practice an enteroclysm every 48 hours to regularize evacuations.
• dry colostomy : colostomy performed in the left half of the colon, the discharge from the stoma consisting of soft or formed fecal residue.
• ileotransverse colostomy :  surgical anastomosis between the ileum and the transverse colon.
• wet colostomy : colostomy in (a) the right half of the colon, the drainage from which is liquid in character, or (b) the left half of the colon following anastomosis of the ureters to the sigmoid or descending colon so that urine is also expelled through the same stoma
• colostomy bag : a receptacle worn over the stoma to receive the fecal discharge from a colostomy.
• Mikulicz colostomy or operation : enterectomy in stages, including exteriorization of the section of intestine to be resected, usually the colon; resection of the exteriorized loop; elimination of the fecal fistula by crushing the spur between the two barrels of the anastomosis; and closure of the fecal fistula.
• colocecostomy / cecocolostomy : the surgical creation of an anastomosis between the cecum and the colon; also, the anastomosis so constructed
• Maydl's operation : colostomy in which the colon is drawn out through the wound and maintained in position by placing a glass rod beneath it until adhesions have formed; of historical interest
• lumbocolostomy : the operation of forming a permanent opening into the colon by an incision through the lumbar region
• colocolostomy : surgical formation of an anastomosis between two portions of the colon
• colofixation : fixation or suspension of the colon
• colopexy : fixation or suspension of the colon by surgical means.
• colohepatopexy : fixation of the colon to the liver to prevent the formation of adhesions between the liver and the stomach.
• cololysis : the division of pericolic adhesions
• colectomy / laparocolectomy : excision of colon
• partial colectomy : excision of a portion of the colon
• hemicolectomy : excision of approximately half of the colon followed by anastomosis
• (enlarged) right hemicolectomy : surgical removal of the right colon (including 10 cm of transverse colon and 10 cm of ileum) followed by ileocolonic anastomosis
• (enlarged) left hemicolectomy : surgical removal of the left colon (distal half of transverse colon and left colon until rectosigmoid junction) followed by colorectal anastomosis
• Hartmann's colostomy, operation or procedure / low Hartmann's resection (LHP) : hemicolectomy, with the proximal end of the colon brought out as a temporary colostomy and the distal stump or rectum not removed (as in RAR) but being closed by suture. Bowel continuity can later be restored with latero-lateral anastomosis, but treatment is usually palliative
• sigmoidectomy / sigmoid colectomy : excision of the sigmoid colon
• complete or total colectomy : excision of the whole colon
• coloproctostomy / colorectostomy : formation of an artificial opening between the colon and rectum
• panproctocolectomy : excision of the entire rectum and colon, with creation of an ileal stoma.
• teniamyotomy : an operation involving a series of transverse incisions of the taeniae coli; done in diverticular disease
• pull-through : the surgical pulling of one segment of intestine through a segment distal to it
• endorectal or ileoanal pull-through procedure or anastomosis / Duhamel, Soave, and Swenson's operation : anastomosis of an ileoanal reservoir to the anal canal by means of a short conduit of ileum pulled through the rectal cuff and sutured to the anus; done to allow continent elimination of feces following colectomy in the management of ulcerative colitis
• colopexotomy : incision and fixation of the colon.
• sigmoidopexy : suspension of the sigmoid colon, usually performed for treatment of rectal prolapse.
• sigmoidoproctostomy / sigmoidorectostomy : the creation of an artificial opening between the sigmoid colon and the rectum; also, the opening so created.
• sigmoidosigmoidostomy :  the operative formation of an anastomosis between two portions of the sigmoid colon; also, the opening so created.
• sigmoidostomy : formation of an artificial opening from the body surface into the sigmoid colon or  the opening produced by this procedure.
• sigmoidotomy : operative incision into the sigmoid colon.
Prevention : ertapenem is more effective than cefotetan in the prevention of surgical-site infection in patients undergoing elective colorectal surgery but may be associated with an increase in C. difficileinfection^ref
• rectum surgery
• proctotomy : incision into the rectum, as for relief of rectal stricture.
• external proctotomy : that done at or below the sphincter.
• internal proctotomy : that done above the sphincter.
• proctectomy : surgical removal of the rectum.
• rectum anterior resection (RAR) with end-to-end colorectal anastomosis for upper and middle rectal tumors when the distal border is > 2 cm
• Miles' operation / abdominoperineal resection (APR) (Miles Sir W.Ernest. A method for performing abdomino-perineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 2:1812-1813 (1908)) : surgical treatment for cancer of the lower sigmoid and rectum, with abdominal removal of the pelvic colon, mesocolon, and adjacent lymph nodes, and wide perineal excision of the rectum and anus, and a permanent left colostomy
• proctorrhaphy / rectorrhaphy : surgical repair of the rectum
• proctosigmoidectomy : excision of the anus, rectum, and sigmoid flexure.
• proctopexy / rectopexy to correct rectocoele : fixation of the rectum to some adjacent tissue or organ by suture
• proctococcypexy : fixation of the rectum to the coccyx by sutures.
• proctoplasty : plastic surgery of the rectum.
• proctocolpoplasty : operative repair of a rectovaginal fistula.
• proctocystoplasty : a plastic operation on the rectum and bladder; operative closure of a rectovesical fistula.
• proctoperineoplasty / proctoperineorrhaphy : plastic repair of the anus and perineum.
• proctocolectomy / coloproctectomy : surgical removal of the rectum and colon
• proctostomy : surgical creation of an artificial opening from the body surface into the rectum.
• hemorrhoidectomy : excision of hemorrhoids.
• Whitehead's operation : treatment of hemorrhoids by excision.
• Barron rubber band ligation : treatment of hemorrhoids by binding them at the base with rubber ligatures so that the distal portion sloughs away within several days.
• anus surgery
• artificial anus : an opening from the bowel formed by the creation of a colostomy.
• pectenotomy : surgical correction of pectenosis by incision of the ring of tissue causing it.
• anoplasty : a plastic or restorative operation on the anus
• peritoneum surgery
• peritoneotomy / celiotomy
• Kocher maneuvre : division of the peritoneum lateral to the duodenum is necessary to palpate the pancreatic head, and division of the peritoneum along the inferior border of the pancreas is required to palpate the body and the tail adequately, in order to detect small islet-tumor
• peritoneopexy : fixation of the uterus by the vaginal route.
• peritoneoplasty / peritonization : the operation of covering denuded areas of abdominal viscera or of the abdominal cavity with peritoneum
• omentectomy / omentumectomy / epiploectomy : excision of all or a portion of the omentum.
• omentopexy / epiplopexy / omentofixation : in general, an operation in which omentum is fastened to some other tissue, especially one in which omentum is used as a circulatory bridge to reduce congestion or provide vascular nutrition.
• Talma's operation : omentopexy in treatment of ascites; of historical interest.
• omentoplasty / epiploplasty  : the use of omental grafts to cover raw surfaces in abdominal surgery
• omentorrhaphy / epiplorrhaphy : suture or repair of the omentum
• omentotomy : incision of the omentum.
• mesenterectomy : resection of mesentery
• mesenteriopexy : fixation or suspension of the mesentery
• mesentorrhaphy / mesenteriorrhaphy : suture or repair of the mesentery
• mesenteriplication : shortening the mesentery by plication
• peritoneal button : a short flanged glass tube for insertion between the peritoneal cavity and a subcutaneous pocket through which peritoneal transudate may be drained.
• celiectomy : surgical removal of an abdominal organ.
• celiocolpotomy :  incision into the abdomen through the vaginal wall.
• celioenterotomy : incision through the abdominal wall into the intestine
• celiomyomotomy : incision into a muscular organ or tumor through the abdominal wall.
• laparocolostomy : surgical creation of a permanent opening into the colon through an incision in the anterolateral wall of the abdomen; colostomy.
• laparocystectomy : removal of a cyst by an abdominal incision.
• laparocystotomy : laparotomy with removal of the contents of a cyst.
• laparoenterostomy : surgical creation of an artificial opening into the intestine through the abdominal wall.
• laparoenterotomy : laparotomy with incision into the intestine.
• laparogastroscopy : examination of the interior of the stomach through an abdominal incision.
• laparogastrostomy : surgical creation of a permanent gastric fistula through the abdominal wall.
• laparogastrotomy / celiogastrotomy : incision into the stomach through the abdominal wall
• laparohepatotomy : incision of the liver through the abdominal wall.
• laparohystero-oophorectomy : laparotomy with removal of the uterus and ovaries.
• laparohysterosalpingo-oophorectomy : removal of the uterus, uterine tubes, and ovaries through an abdominal incision.
• laparoileotomy : laparotomy with incision of the ileum.
• laparorrhaphy / celiorrhaphy : suture or repair of the abdominal wall
• laparosalpingectomy / celiosalpingectomy : removal of a uterine tube through an abdominal incision
• laparosalpingo-oophorectomy : removal of a uterine tube and ovary through an abdominal incision.
• laparosalpingostomy : formation of an opening in the oviduct through an abdominal incision.
• laparosalpingotomy / celiosalpingotomy : incision of a uterine tube through an abdominal incision
• laparosplenectomy : laparotomy with excision of the spleen.
• laparosplenotomy : laparotomy to gain access to the spleen, usually for the purpose of draining a cyst or abscess of the spleen.
• laparotyphlotomy : incision into the cecum through the flank.
• Ladd's procedure : surgical cutting of Ladd's bands to correct intestinal malrotation and obstruction.
• abdominal hernial surgery
• Brunschwig's operation : technique developed by Brunschwig for resection of very extensive pelvic tumors. Was at first developed for rectal cancers, but later extended for other tumors with resection of the bladder en uterus (Brunschwig A. Excision of pelvic viscera for advanced carcinoma a one-stage abdominoperineal operation with end colostomy and bilateral implantation into the colon above the colostomy. Cancer 1:177-185 (1948))
• endoherniorrhaphy : surgical repair of a hernia by suture of the interior of its sac
• hernioappendectomy : herniotomy combined with appendectomy.
• hernioenterotomy : herniotomy conjoined with enterotomy.
• herniolaparotomy : laparotomy for the treatment of hernia.
• herniopuncture : surgical puncture of a hernia.
• annulorrhaphy : closure of a hernial ring or defect by sutures.
• herniotomy / celotomy / kelotomy : a surgical operation for the repair of hernia
• herniorrhaphy / hernioplasty : surgical repair of a hernia is one of the most common surgical procedures performed in the USA, with 700,000 operations performed each year. Hernia repair consists of :
• the sac and its contents
• the defect in the delimiting structure
The sac with a narrow neck should be closed at its neck after evacuating the visceral contents, and  the excess sac should be excised. The sliding hernia is a special case in terms of handling the sac. In this hernia, the visceral peritoneum covering a portion of a retroperitoneal organ makes up a portion of the sac, requiring that the retroperitoneal organ also be included in the herniated tissues. The essential element in repairing the sliding hernia is a good repair of the abdominal wall defect.
• effective repair of the abdominal wall
• relaxing incision
• use of musculoaponeurotic or aponeurotic flaps
• nonviable free grafts
• collagen
• autologous fascia lata
• homograft aponeurotic structures
• prosthetic materials :
• plug : 8 layers of meshes used to obliterate the internal inguinal ring. Intrabdominal hypertension opens the plug preventing outcome of the reduced hernia sac. Petals prevent collapse of the plug, common with hand-made plugs.
• prosthetic mesh (Usher, 1958) 5x10 cm with the long axis along the inguinal canal, which is no longer sutured. It has a lateral incisure ending in a hole to allow transit of the spermatic cord.
• polypropylene mesh (Atrium^® , Marlex^® [Bard Benelux, Nieuwegein, the Netherlands] or Prolene^® (Ethicon, Johnson & Johnson, Cincinnati, OH))
• strength
• flexibility
• durability
• tailoring
• lack of stimulation of inflammatory response
• promotion of fibroblastic response and Ingrowth
• composite polypropylene/polyglactin 910 (Vypro II^®)
• expanded polytetrafluoroethylene sheet
• tantalium wire mesh

• truss : an elastic, canvas, or metallic device for retaining a hernia reduced within the abdominal cavity.
Operations classified per disease :
• omphalocele : Schuster technique : covering the sac with prosthetic sheeting followed by progressive reduction of the contents into the abdominal cavity.
• inguinal hernia
• open hernia repair (OHR) :
• conventional OHR : inguinal canal repaired without mesh prosthesis
• open anterior repair : under local, spinal, or general anesthesia
• Bassini's operation (1887) : incision of aponeurosis of external oblique muscle under guidance of a probe introduced through the external inguinal orifice => isolation of the sac from the elements of the spermatic cord => incision of fascia trasversalis => opening of the sac => reduction of content back into abdominal cavity => high ligation of the sac at the level of the collar => excision of sac body and fundus => single stitch suture of the triple muscle layer (internal oblique muscle, transverse muscle (joint tendon) and fascia trasversalis) to the inguinal ligament  (ie . reinforcement of the posterior wall of the inguinal canal) => suture of the aponeurosis of the external oblique muscle in front of the spermatic cord (ie .placement of the spermatic cord under the external oblique anastomosis)

Side effects : the union of the joint tendon to the inguinal ligament causes tension of the suture line, expecially at the level of the extremities (pubic tubercle and internal inguinal orifice), which in facts are the most common sites of hernia relapse. The tension due to the traction of the tissues also cause a transient local pain and antalgic limitation of walking
• Chester McVay repair (1939) : he demonstrated the precise insertion of the tranversus abdominis muscle and transversalis fascia to the Cooper's ligament. He used Cooper's ligament for the femoral hernia repair by the inguinal approach. The suture of the posterior wall of the inguinal canal is anchored to the aponeurosis of the transverse muscle and the fascia trasversalis, and down to Cooper ligament, iliopubic tract and femoral sheath
• Marcy operation (1871) : indicated for external oblique hernias when the posterior wall of the inguinal canal is tonic and robust; reconstruction is limited to closure of the stressed internal inguinal ring
• Shouldice operation (1953) : reconstruction of the posterior wall of the inguinal canal with a quadruple continue and sovrapposed suture. The first double suture involves (come and go) the fascia trasversalis from pubic tubercle to the internal inguinal ring; the second double suture involves (come and go) the inferior border of the internal oblique muscle and the transverse muscle upstream and the inguinal  ligament downstream. The complete dissection lends itself to the discovery of secondary hernias. The procedure is designed so that these secondary defects are easily incorporated into the repair. Mesh is employed infrequently, only in those cases where there is a lack of tissue or scarring has minimized flexibility. Performed under local anesthetic, complications are minimal and early return to work is a feature. With a more than 50-year history of thousands of successful operations annually, the Shouldice procedure should continue to merit consideration by all surgeons striving for excellence in hernia repair^ref.
• Macewen's operation : an operation for the radical cure of hernia by closing the internal ring with a pad made of the hernial sac
• open posterior repair : inguinal canal reconstruction from inside under spinal or general anesthesia; avoids scar
• iliopubic tract repair
• Nyhus technique
• Halsted's operation : transposition of the spermatic cord above the external oblique aponeurosis
• McBurney's operation : the sac is exposed, ligated, and cut off at the internal ring; the skin is turned in and stitched to the underlying tendinous and ligamentous structures.
• hernioalloplasty : repair of the hernia door trough a parietal prosthesis, expecially recommended at advanced age, meiopragia, biological degeneration of the connective tissue or relapse after  previous operations (high risk of relapse)
• open inguinal or anterior route
• open posterior or preperitoneal route (Stoppa procedure) : umbilicopubic laparotomy => detachment of peritoneal sac from the posterior surface of the abdominal wall => reduction of the hernial sac => a wide mesh surrounding the peritoneum is placed without suturing the hernia doors. Intraabdominal hypertension permanently fixes the mesh in a preperitoneal position and prevents herniation. Indications :
• bulky bilateral hernias
• relapse after inguinal hernioalloplasty
• hernia associated to laparocele
• laparoscopic route
Prosthetic mesh allowstension-free hernioplasty and day-hospital regimen:
• Irving Lichtenstein open tension-free hernioplasty or onlay patch repair (1987)^ref : the prosthetic mesh is achored with separated stitches or continue suture to the pubic tubercle, the inguinal ligament and the conjoined tendon. Without the risk of serious morbidity, it is now readily performed using local anesthesia in patients previously considered unsuitable for surgery. Fears of serious complications related to mesh implantation have proved to be without foundation. As a local anesthetic day care technique without the need for complex and expensive instrumentation, overall costs can be kept to a minimum without compromising the safety or the long-term success of the procedure. It is a straightforward technique to learn, with high patient acceptability and an exceedingly low recurrence rate. At present it must be considered the gold standard of groin hernia repair^ref
• Gilbert-Rutcow-Robbins or mesh-plug open tension-free hernioplasty : 3-5 cm incision over external inguinal ring, 1-2 cm or no incision of aponeurosis of external oblique muscle, no section (only longitudinal dissection) of cremaster (=> cremasteric reflex is spared), the sac is isolated by the funicle and deepened rather than resected => plug fixed circumferentially in the preperitoneal space with nonreabsorbable monofilament thread (sparing iliohypogastric and ilioinguinal nerves), mesh (further containment and stimulation of fibroplastic proliferation) below the aponeurosis of the external oblique muscle (not to be fixed or single stitch to pubis) and aroud the spermatic cord (closed intraoperatorially with a stitch) => single stitch to close the dissected aponeurosis of external oblique muscle and 4 stitches to close skin incision. Locoregional anesthesia allows cough testing of plug movement during operation. Relapses in <1%.
• PerFix^® plug (C.R. Bard. Inc., Murray Hill, NJ) and patch repair :
• Prolene^® Hernia System bilayer patch repair :
• Trabucco's sutureless preshaped herniography : no fixation of the mesh
Recurrence rates <1% and good longterm safety data : recent study showed 4.9% recurrence^ref. No sexual dysfunction after repair^ref
• Valenti's technique :
Complications specific to OHR :
• testicular atrophy
• vas deferens transection
• scrotal ecchymosis
• hydrocele
• laparoscopic hernioplasty or hernia repair (LHR) accounts for 15% to 20% of hernia operations in America and around the world.
• intraperitoneal onlay mesh repair (IPOM) and GORE-TEX DualMesh Plus biomaterial with holes fixed with titanium spiral tacks (Protack, AutoSuture, Tyco Healthcare)
• transabdominal pre-peritoneal (TAPP) repair : still the most widely performed
• totally extraperitoneal (TEP) repair : is becoming more popular
Staples may safely be placed during laparoscopic hernia repair in Cooper's ligament, tissues superior to the lateral iliopubic tract, the transversus abdominis aponeurotic arch, and the iliopubic tract at its insertion onto Cooper's ligament, but not in tissues inferior to the lateral iliopubic tract as they may result in injury to the lateral femoral cutaneous nerve or the genitofemoral nerve. Staples should also not be placed within the triangle of doom, owing to the risk of major vascular injury. General anesthesia is required. Either an abdominal or preperitoneal approach is possible. The use of prosthetic mesh is required in all variations
Complications specific to laparoscopic repair :
• major vessel injury
• urinary retention
• trocar site hernia
• small bowel obstruction
• umbilical hernia : Mayo's operation : excision followed by transverse overlapping of the abdominal aponeuroses
• femoral hernia : Moschcowitz's operation : by the inguinal approach.
Complications of both open and laparoscopic repair :
• injury to motor or sensory nerves : injury to the iliohypogastric, ilioinguinal, and genital branch of the genitofemoral => neuralgia / chronic pain (most prevalent and difficult to treat)
• traction
• cautery
• nerve transection
• entrapment within a stitch.
• ilioinguinal nerve entrapment
• genital branch of genitofemoral nerve entrapment
• wound infection can prolong care and promote recurrence
• vascular injuries => hemorrhage (bruising and hematoma/seroma are banal and usually resolved spontaneously)
• visceral injury (nearby organs)
• bowel or bladder injury
• urinary retention
• recurrence 5 to 25 years after repair. Rate of recurrence : inguinal hernia recurrence: 5-8% (direct slightly higher recurrence then indirect; lower recurrence rate with tension-free mesh; recurrence after recurrent hernia repair: 30%). Risks of recurrence :
• longstanding large hernia (poor tissue quality)
• overly rapid return to daily activity after repair
• incomplete surgical dissection
• comorbid condition
• obesity
• corticosteroid use
• chronic obstructive lung disease
• Battle's operation : an operation for appendicitis in which the rectus muscle is temporarily retracted
• Hochenegg's operation : total excision of the rectum with preservation of the anal sphincter; of historical interest.
• perineoplasty : plastic surgery of the perineum
• proctoperineoplasty
• colpoperineoplasty
• perineorrhaphy : suture of the perineum, performed for the repair of a laceration
• Emmet's operation : a method of repairing a lacerated perineum
• colpoperineorrhaphy
• perineotomy : surgical incision through the perineum
• Lane's operation : the operation of dividing the ileum near the cecum, closing the distal portion and anastomosing the proximal end with the upper part of the rectum or lower part of the sigmoid, thus eliminating the colon from the fecal current.
• Polya's operation : anastomosis of the transected end of the stomach to the side of the jejunum following subtotal gastrectomy.
• Duhamel operation : the treatment of congenital megacolon by a modification of the pull-through operation and establishment of a longitudinal anastomosis between the proximal ganglionated segment of colon and the rectum, leaving the rectum in situ.
• Soave operation : treatment of congenital megacolon by an endorectal pull-through anastomosis, with normal colon connected to the anus through a rectum denuded of mucosa.
• State operation : the treatment of congenital megacolon by end-to-end anastomosis of the colon from above the aganglionic segment to the upper part of the rectum.
• Swenson's operation : an operation for congenital megacolon, consisting of removal of the rectum and the aganglionic segment of the intestine and an ileoanal pull-through procedure with preservation of the anal sphincters.
• omphalectomy : excision of the umbilicus
Complications :
• fibrous adhesions

Pathogenesis : SP promotes peritoneal adhesion formation by limiting fibrinolytic activity in the postoperative peritoneum, thus enabling fibrinous adhesions to persist^ref
Therapy : NK-1R antagonists
• adrenalectomy / suprarenalectomy : excision of one (unilateral adrenalectomy) or both (bilateral adrenalectomy) adrenal glands
• genital surgery
• male genital surgery
• testis surgery
• orchiectomy / orchidectomy : excision of one or both testes; if it is bilateral, the individual is incapable of reproduction
• radical inguinal orchiectomy : surgical removal of a testis and of the spermatic cord up to the internal inguinal ring
• White's operation : castration for hypertrophy of the prostate.
• Huggins' operation : orchiectomy performed for cancer of the prostate.
• orchiopexy / orchiorrhaphy  / orchidopexy : surgical fixation in the scrotum of an undescended testis. Shoemaker technique : inguinal cutaneous incision => isolation of the retained testis => funicololysis => preparation of dartoic pouch or scrotal incision => lowering of the testis into the scrotum => suture
• Ombrédanne's operation : transscrotal orchiopexy
• Torek operation : an operation for an undescended testes
• Bevan's operation : an operation for an undescended testes, by which the testicle is brought down permanently into the scrotum.
• Fuller's operation : perineal incision and drainage of the seminal vesicles; of historical interest.
• orchioplasty / orchidoplasty : plastic surgery of the testis
• orchiotomy / orchotomy : incision and drainage of a testis.
• orchidoepididymectomy : the operation of excising the testis and epididymis.
• epididymodeferentectomy / epididymovasectomy : excision of both the epididyma and a large portion of both ducti deferentes
• epididymotomy : incision of the epididymis
• epididymovasostomy : surgical creation of a new communication between the epididymis and a formerly distal portion of the vas (ductus) deferens
• funiculopexy : surgical fixation of the spermatic cord to the surrounding tissues in the correction of undescended testes
• orchifuniculectomy : excision of one or both testes and spermatic cord. The aponeurosis of external oblique muscle is incised as in open hernia repair, the gubernaculum testis is incided, and the spermatic vessels are ligated at the level of the internal inguinal ring.
• detorsion : the correction of a twisting or deformity, as the reduction of torsion of the testis
• vasectomy / vasoresection / vasosection : surgical removal of the ductus (vas) deferens, or of a portion of it; done to induce infertility (assessed with an azoospermic postvasectomy semen analysis (PVSA)) or in association with prostatectomy
• cross-over vasectomy : vasectomy in which the right and the left vas deferens are transected, the lower portion of each (the portions still attached to the epididymis) then being tied together. The technique prevents recanalization while allowing surgical reconstruction
• spermatocelectomy : excision of a spermatocele.
• spermatocystectomy : excision of the seminal vesicles.
• spermatocystotomy : incision of the seminal vesicles.
• spermectomy : excision of a portion of the spermatic cord.
• prostate surgery
• prostatectomy : surgical removal of the prostate or of a part of it.
• transurethral prostatectomy / transurethral prostatic resection / transurethral resection of the prostate (TURP) : resection of the prostate by means of a cystoscope with a telescopic electric knife passed through the urethra. The TURP requires an anesthetic and takes about 30-60' to perform. A tube or catheter is inserted into the bladder and is left in place for 24 to 48 hours. The hospitalization lasts from 1-3 days and requires 2 weeks of severe activity restrictions and another 2 weeks of modest restrictions
• open prostatectomy : the telescopic approaches (TURP, TUIP, laser, hyperthermia and balloons) are ineffective or impossible with prostate glands that are > 75-100 g
• radical prostatectomy : removal of the prostate with its capsule, seminal vesicles, ductus deferens, some pelvic fasciae, and sometimes pelvic lymph nodes; performed via either the retropubic or the perineal route.
• perineal prostatectomy / Young's operation : removal of the prostate through an incision in the perineum
• suprapubic transvesical prostatectomy / McGill's operation : removal of the prostate through an incision above the pubis and through the urinary bladder.
• Freyer's operation : a method of performing suprapubic enucleation of the hypertrophied prostate; of historical interest.
• Dittel's operation : enucleation of an enlarged prostate through an external incision; of historical interest.
• retropubic prevesical prostatectomy : removal of the prostate through a suprapubic incision but without entering the urinary bladder.
Hagner bag : an inflatable rubber bag to be used by traction through the urethra to prevent hemorrhage following prostatectomy.
• Pilcher bag : a modification of the Hagner bag which provides urethral drainage as well as hemostasis.
Complications :
• early complications
• hemorrhages
• resection syndrome
• urinary tract infections
• urinary retention
• late complications
• urinary incontinence
• urethral stenosis (5-10%) : catheterism => ischemia => necrosis => scar tissue
• bladder neck sclerosis (5%)
• sexual impotence (10%) : retrograde ejaculation
• transurethral incision of the prostate (TUIP) makes a simple cut or incision along the entire length of the prostate. Because of the circular muscle fibers running around the prostate, the TUIP allows the bladder neck to spring open and allows free urinary flow. TUIP is particularly beneficial for smaller prostates (< 20 g) and does have a lower incidence of retrograde ejaculation. Hospital stays and recovery are much shorter
• transurethral laser incision of the prostate (TULIP)
• transurethral laser removal of the prostate
• transurethral vaporization of the prostate (TUVP)
• transurethral vaporization-resection of the prostate (TUVRP)
• transurethral needle ablation (TUNA) of the prostate
• scrotum surgery :
• scrotectomy : partial or complete excision of the scrotum
• scrotoplasty / oscheoplasty : plastic surgery of the scrotum
• penis surgery :
• circumcision / acucullophallia / peritomy / posthetomy : the cutting off of the foreskin, practiced as a religious rite by Jews and Muslims, useful for therapy of phymosis and prophylaxis of urethrocystitis. Ritual circumcision performed on 8-day-old male infants is rooted in the Bible and is discussed in the earliest Jewish sources. The practice has been observed across the generations in every Jewish community in Israel and the Diaspora. According to Jewish ritual, the mohel--the ritual circumcisor--amputates the foreskin and then folds back the membrane that lies beneath it. This is followed by metzitza--"suction"--a practice performed throughout the ages by mouth. Halakhic literature sets down strict rules regarding this surgical intervention in order to prevent medical complications for the newborn. Metzitza by mouth has been recognized as a risk factor in the transfer of infection from the mohel to the newborn. A recent study relates to 8 infants who became infected with herpes virus as a result of the procedure. The custom of metzitza by mouth has been the subject of extensive rabbinic discussion since the middle of the 19th century. A better understanding of the historical, social and cultural background of the issue might allow us to formulate alternatives to the practice. Metzitza was performed throughout the generations by mouth because that was the recognized method of disinfection at the time. Beginning in the 19th century, medical and esthetic considerations have led to the abolishment of metzitza by mouth or to its performance by way of a swab or through a glass tube in order to prevent infection. Ideological tendentiousness is evident in both approaches: Should the medical risks of metzitza by mouth be overlooked and denied out of loyalty to ancient tradition, thus allowing the practice to be continued? Or should the recognition of such risks along with esthetic considerations lead to changes in halakhic thinking to perform the metzitza in a hygienic technique? Historically, the issue of metzitza by mouth has been a bone of contention between traditional outlook and modern halakhic thinking, which takes into consideration advances in medical knowledge. In light of the reports in the medical literature about complications in the wake of metzitza by mouth, some of the halakhic rulings regarding circumcision should be reconsidered. Clinically, it is important to raise the medical community's awareness of the phenomenon and treat infected infants accordingly^ref
• penectomy : surgical removal of the penis.
• glanuloplasty : plastic surgery on a glans, such as the glans penis to correct hypospadias.
• total glans resurfacing (TGR), for premalignant lesions who recur after local excision, topical chemotherapy, laser or cryotherapy, involves removing the glans and subcoronal epithelial and subepithelial tissues down to the corpus spongiosum of the glans and Buck's fascia at the coronal sulcus. The denuded glans penis is then covered with an extra-genital skin graft^ref
• female genital surgery
• ovary surgery
• oophorectomy / ovariectomy : the removal of an ovary or ovaries; if done bilaterally, the individual is incapable of reproduction
• abdominal ovariotomy : ovariotomy performed through the abdominal wall.
• vaginal ovariotomy : ovariotomy performed through the vagina.
• oophorocystectomy : excision of an ovarian cyst.
• oophorohysterectomy : surgical removal of the uterus and ovaries
• oophoropexy / ovariopexy : the operation of elevating and fixing an ovary to the abdominal wall
• oophoroplasty : plastic surgery of the ovary.
• oophorosalpingectomy / salpingo-oophorectomy / salpingo-ovariectomy / ovariosalpingectomy / tubo-ovariotomy : surgical removal of a uterine tube and ovary
• oophorostomy : the making of an opening into an ovarian cyst.
• oophorotomy : incision of an ovary.
• uterine tube surgery
• salpingectomy / tubectomy : surgical removal of the uterine tube
• salpingolysis : surgical lysis of adhesions involving the uterine tubes.
• salpingopexy : operative fixation of the uterine tube.
• salpingoplasty / tuboplasty : plastic repair of the uterine tube
• salpingorrhaphy : suture of the fallopian tube.
• salpingostomatomy / salpingostomatoplasty : surgical resection of a portion of the uterine tube, with creation of a new abdominal ostium.
• salpingostomy : formation of an opening or fistula into a uterine tube or surgical restoration of the patency of a uterine tube.
• salpingotomy : surgical incision of a uterine tube.
• Pomeroy's operation : a method of sterilization in the female, in which the fallopian tube is picked up about two inches from the uterine cornua, a chromic gut ligature tied around the loop without crushing it, and the tied loop is then resected.
• tubal ligation : sterilization of the female by constricting, severing, or crushing the uterine tubes; constriction may be with an encircling plastic ring or other ligature.
• Irving's sterilization operation : a method of tubal ligation in which the uterine tubes are ligated and severed and the proximal ends are sewn into the myometrium.
• uterus surgery
• trachelopexy : surgical fixation of the neck of the uterus to some other part
• tracheloplasty : plastic repair of the cervix uteri
• trachelorrhaphy : suture of the lacerated cervix uteri
• trachelosyringorrhaphy : trachelorrhaphy for fistula of the vagina
• trachelotomy : incision of the cervix uteri.
• cerclage : encircling of a part with a ring or loop, such as encirclement of the incompetent cervix uteri with suture material, or the binding together of the ends of a fractured bone with a metal ring or wire loop (tiring)
• hystereurysis : dilation of the os uteri
• hysterocleisis : surgical closure of the ostium uteri.
• hysterocolpectomy : surgical removal of the uterus and vagina.
• hysterocystocleisis / Bozeman's operation : the operation of turning the cervix uteri into the bladder and suturing it; done for the relief of vesicouterovaginal fistula or ureterouterine fistula
• hysterolysis : the operation of loosening the uterus from its attachments or adhesions.
• hysteromyotomy : incision of the uterus.
• hysterectomy : the operation of excising the uterus
• partial, subtotal, supracervical or supravaginal hysterectomy : hysterectomy in which the cervix is left in place.
• complete or total hysterectomy / panhysterectomy : hysterectomy in which the uterus and cervix are completely excised
• Piver-Rutledge-Smith extended or radical hysterectomy (1974^ref) : hysterectomy with pelvic lymphadenectomy and wide lateral excision of parametrial and paravaginal supporting structures; called also Wertheim's operation (removal of the uterus, tubes, parametrium, tissues surrounding the upper vagina, and pelvic lymphatics; Wertheim J. Die erweiterte abdominale Operation bei Carcinoma Colli uteri (auf Grund von 500 Falle) Book, ed.Urban & Schwarzenberger, Berlin) or, when done by the vaginal route, Schauta's operation.
• class I : extrafacial hysterectomy, incision of pubocervical ligament, allowing lateral displacement of ureter
• class II : ablation of medial half of cardinal and uterosacral ligaments and upper third of vagina
• class III : ablation of whole cardinal and uterosacral ligaments and upper third of vagina
• class IV : ablation of whole periurethral tissues and upper vesical artery and three-quarters of vagina
• class V : ablation of portions of distal ureter and vagina
• abdominal hysterectomy / abdominohysterectomy / celiohysterectomyn / laparohysterectomy : excision of the uterus through an incision in the abdominal wall
• cesarean hysterectomy : cesarean section followed by removal of the uterus.
• vaginal hysterectomy : excision of the uterus through the vagina
• hysteropexy / utheropexy : the fixation of a displaced uterus by a surgical operation. It may be done by ventrofixation, shortening of the round ligaments, shortening of the sacrouterine ligaments, or shortening of the endopelvic fascia. It is called abdominal or vaginal, depending on whether the uterus is fastened to the abdominal wall or to the vagina.
• hysterorrhaphy : the operation of suturing of the lacerated uterus.
• hysterosalpingectomy : excision of the uterus and uterine tubes.
• hysterosalpingography / uterosalpingography / uterotubography / hysterotubography / metrosalpingography / metrotubography : radiography of the uterus and uterine tubes after the injection of opaque material
• hysterosalpingo-oophorectomy : excision of the uterus, uterine tubes, and ovaries.
• hysterosalpingostomy : the operation of forming an anastomosis between the uterus and the oviduct after excision of a strictured or obstructed portion of the tube.
• hysterotomy / metrotomy : incision of the uterus, usually for delivery of a fetus.
• abdominal hysterotomy / abdominohysterotomy / abdominouterotomy / laparohysterotomy : incision of the uterus through the wall of the abdomen
• vaginal hysterotomy : incision of the uterus through the vagina.
• hysterotrachelectasia : surgical dilation of the cervix and uterus.
• hysterotrachelectomy / cervicectomy / trachelectomy : excision of the cervix uteri
• hysterotracheloplasty : plastic repair of the cervix uteri; tracheloplasty.
• hysterotrachelorrhaphy : suture of the cervix uteri.
• hysterotrachelotomy : incision of the cervix uteri.
• Emmet's operation : trachelorrhaphy, or suture of the edges of a lacerated cervix uteri
• metroplasty : reconstructive surgery on the uterus
• Alexander-Adams operation : shortening of the round ligaments to repair displacement of the uterus.
• Basset's operation : a method of dissecting the inguinal glands in radical operations for cancer of the vulva.
• Bozeman's operation / hysterocystocleisis : the operation of turning the cervix uteri into the bladder and suturing it; done for the relief of vesicouterovaginal fistula or ureterouterine fistula
• Dührssen's operation : vaginofixation of the uterus.
• Estes' operation : implantation of an ovary into a uterine cornu; performed for sterility when the tubes are absent.
• Gilliam's operation : an operation for retroversion of the uterus by drawing a loop of each round ligament through the abdominal wall and fixing the loops to the abdominal fascia.
• Gigli's operation : lateral section of the os pubis by means of Gigli's wire saw; done to permit delivery of the fetus in difficult labor.
• Haultain's operation : a modification of the Huntington operation for replacement of a chronically inverted uterus, involving a posterior incision in the uterus through the cervical ring.
• Huntington's operation : transabdominal repair of a chronically inverted uterus. It is done by grasping the invaginated portion of the uterus with forceps; as the uterus is pulled up, additional forceps are placed sequentially lower down, and upward traction is applied. After the uterus is in place, the position is maintained by packing through the vagina.
• McDonald operation : an operation for incompetent cervix, in which the cervical os is closed with a purse-string suture.
• Küstner operation : replacement of an inverted uterus through an incision made in the cervix and uterus along the posterior surface.
• Latzko's operation : a method of repairing a vesicovaginal fistula by using mucosa denuded from the posterior wall of the vagina as a flap to cover the fistula.
• Le Fort-Neugebauer operation : the operation of uniting the anterior and posterior vaginal walls along the middle line for the repair or prevention of prolapse of the uterus.
• Olshausen's operation : the operation of fixing or suturing the uterus to the abdominal wall for the cure of retroversion.
• Shirodkar's operation : an operation for incompetent cervix in which the cervical os is closed with a surrounding purse-string suture.
• Spinelli's operation : the operation of splitting the anterior wall of the prolapsed inverted uterus, reversing the organ, and restoring it to the correct position.
• Sturmdorf's operation : conical excision of the diseased endocervix.
• Watkins' interposition operation : an operation for uterine prolapse and procidentia uteri in which the bladder is separated from the anterior wall of the uterus so that the uterus is left in a position to support the entire bladder
• Fothergill or Manchester operation : an operation for uterine prolapse comprising dilation and curettage, anterior repair, amputation of the vaginal portion of the cervix, shortening of the cardinal ligaments, and posterior colpoperineorrhaphy.
• uterine myomectomy / hysteromyomectomy / fibroidectomy / fibromectomy : surgical excision of a uterine leiomyoma using an abdominal (abdominal myomectomy / celiomyomectomy / laparomyomectomy) or vaginal (vaginal myomectomy / colpomyomectomy) approach
• adnexectomy : excision or removal of the adnexa uteri
• myomohysterectomy : surgical removal of a myomatous uterus.
• uterine curettage
• medical curettage : the induction of bleeding from the endometrium by administration and withdrawal of any progestational agent.
• suction or vacuum curettage / vacuum aspiration : removal of the uterine contents, after cervical dilation, by means of a hollow curet introduced into the uterus, through which suction is applied
• vagina surgery
• colpectomy / vaginalectomy / vaginectomy : excision of the vagina
• hemicolpectomy : excision of half the vagina
• colpeurysis : dilation of the vagina, particularly with a bag or sac.
• colpoceliocentesis : puncture of the abdominal cavity through the vagina, usually the posterior vault
• colpoceliotomy : incision into the abdomen through the vaginal wall
• colpocleisis : surgical closure of the vaginal canal
• colpoplasty / vaginoplasty : plastic surgery of the vagina
• colpoperineoplasty / vaginoperineoplasty : plastic surgery of the vagina and perineum
• colpoperineorrhaphy / vaginoperineorrhaphy : suture repair of the vagina and perineum
• colpopexy / vaginofixation / vaginapexy / vaginopexy : suture of the prolapsed vagina to a surrounding structure such as the abdominal wall
• abdominal sacrocolpopexy is an abdominal-prolapse repair that restores pelvic anatomy in most women, although data on long-term (5 to 10 years) durability are limited^ref. In sacrocolpopexy, graft material is attached between the vagina and sacrum, supporting the vagina
• with the addition of standardized Burch colposuspension is effective in treating stress incontinence, and there is evidence of its durability during 10 years of follow-up^{ref1, ref2, ref3, ref4}. Performed through the same incision as the sacrocolpopexy, the Burch colposuspension consists of suturing periurethral vaginal tissue to the iliopectineal (Cooper's) ligaments on each side to support the urethra.

Pelvic-organ prolapse of the vaginal apex, due to the loss of normal support, results in invagination into the vagina and in more severe stages of prolapse, outside the vaginal introitus. In the abdominal sacrocolpopexy (Panel A), grafts sutured to the posterior and anterior aspects of the vagina suspend the vaginal vault. The other end of the graft is sutured to the anterior longitudinal ligament of the sacrum. In the Burch colposuspension (Panel B), the urethra is supported by sutures in the vagina at the level of the midurethra and urethrovesical junction to the iliopectineal line (Cooper's ligament) with the use of suture bridges.
Paravaginal repair, in which the lateral vagina is reattached to the pelvic sidewall, can be performed with sacrocolpopexy. Although paravaginal repair alone is less effective than Burch colposuspension to treat stress incontinence^ref, some surgeons combine paravaginal repair with sacrocolpopexy and Burch colposuspension with the goal of enhancing vaginal support, although efficacy data are lacking for this approach.
• colpopoiesis : the creation of a vagina by plastic surgery.
• colporectopexy : suspension of a prolapsed rectum by suture to the vaginal wall.
• colporrhaphy : 1. the operation of suturing the vagina.  2. the operation of denuding and suturing the vaginal wall for the purpose of restructuring the vagina.
• colpostenotomy : a cutting operation for stricture or atresia of the vagina
• culdocentesis : aspiration of fluid from the rectouterine space by puncture of the apex of the vaginal wall.
• colpotomy / vaginotomy : incision of the vagina with entry into the cul-de-sac
• posterior colpotomy / culdotomy : incision into the cul-de-sac (pouch of Douglas)
• colpoureterocystotomy : the exposure of the orifices of the ureters by cutting through the walls of the vagina and bladder.
• colpoureterotomy : incision of the ureter through the vagina, performed for the relief of ureteral stricture.
• hymenorrhaphy : the closure of the vagina by sutures at the hymen.
• hymenotomy : surgical incision of the hymen.
• vulvectomy : excision of the vulva
• episioperineoplasty : plastic repair of the vulva and perineum
• episioperineorrhaphy : the suturing of the vulva and perineum
• episioplasty : plastic repair of the vulva
• episiorrhaphy : the suturing of the labia majora for repair of the vulva and perineum
• episiostenosis : the narrowing of the vulvar orifice
• clitoridectomy / clitorectomy : excision of the clitoris
• clitoridotomy / hoodectomy : incision of the clitoris
• clitoroplasty : plastic surgery of the clitoris
• clitorotomy : surgical incision of the clitoris
• obstetric surgery
• embryectomy : excision of the embryo in extrauterine pregnancy
• ex utero intrapartum therapy (EXIT) allows therapeutic interventions on the neonate while maintaining fetoplacental circulation (uteroplacental blood flow and gas exchange). This goal is achieved with the use of inhalational agents to relax uterine tone, a continuous amnioinfusion to stabilize uterine volume, and partial exposure of the fetus. Indications include fetal lesions causing extrinsic or intrinsic airway obstruction (reversal of tracheal occlusion for congenital diaphragmatic hernia (CDH), resection of massive congenital cystic adenomatoid malformation (CCAM) of the lung, congenital high airway obstruction syndrome (CHAOS), EXIT-to-extracorporeal membrane oxygenation (ECMO) for a fetus with CDH and a cardiac defect, unilateral pulmonary agenesis, and thoracoomphalopagus conjoined twins). However, fetuses with other anomalies that may compromise neonatal resuscitation can also benefit from this approach. The EXIT procedure differs significantly from a cesarean delivery, and caution must be taken to avoid maternal morbidity. Some fetuses require initial tracheotomy at the time of EXIT to secure the airway. In all cases, the EXIT procedure provides time on uteroplacental gas exchange to perform procedures such as direct laryngoscopy, bronchoscopy, tracheotomy, arterial and venous access, resection of neck or lung masses, and ECMO cannulation, thereby converting an emergent crisis into a controlled situation.
• amniotomy : deliberate rupture of the fetal membranes to induce labor
• episiotomy : surgical incision into the perineum and vagina to prevent traumatic tearing during delivery.
• caesarean section / abdominal delivery : transverse incision through the abdominal and lower uterine walls for delivery of a fetus
• conservative
• radical
• elective
• programmed
• urgent
• classic or corporeal cesarean section : cesarean section in which the upper segment, or corpus, of the uterus is incised.
• extraperitoneal cesarean section : cesarean section performed without incision of the peritoneum, the peritoneal fold being displaced upward and the bladder being displaced downward or to the midline, the uterus then being opened by an incision in its lower segment.
• Latzko's cesarean section or operation : extraperitoneal cesarean section with the uterine incision made through one side of the lower segment of the uterus.
• Waters' operation : a form of extraperitoneal cesarean section.
• lower segment or cervical cesarean section : cesarean section in which the lower uterine segment is incised, either transperitoneally or extraperitoneally.
• low vertical cesarean section : cesarean section done transperitoneally with a low vertical uterine incision that is usually made after downward reflection of the bladder.
• Munro Kerr cesarean section : cesarean section in which the lower uterine segment is opened transversely through the uterovesical fold, without displacement of the bladder.
• Porro cesarean section : cesarean section with extirpation of the uterine corpus and ovaries; of historical interest.
• transperitoneal cesarean section : cesarean section performed with an incision through the uterovesical fold of peritoneum.
• transverse cesarean section : cesarean section done transperitoneally with incision of the enterovesical peritoneum and downward displacement of the bladder followed by a low transverse version of the uterus.
Indications :
• absolute indications :
• acute fetal sufference at onset of labor
• chronic fetal sufference (IUGR and oligohydramnios)
• placenta previa
• funicular prolapse
• untempestive placental detachment
• fetal-pelvic disproportion due to fetal megalosomaia, anomalous presentation (brow or ), or pelvis
• relative indications :
• podalic presentation in nullipara
• nullipara aged > 39 years
• maternal diabetes mellitus, preclampsia or nephropathies
• matrnal HIV
• ART
• previous caesarean delivery
Epidural analgesia does not seem to be associated with an increased risk of caesarean section (odds ratio 1.03, 95% confidence interval 0.71 to 1.48) but may be associated with an increased risk of instrumental vaginal delivery (2.11, 0.95 to 4.65). Epidural analgesia was associated with a longer second stage of labour (weighted mean difference 15.2 minutes, 2.1 to 28.2 minutes). More women randomised to receive epidural analgesia had adequate pain relief, with fewer changing to parenteral opioids than vice versa (odds ratio 0.1, 0.05 to 0.22)^ref
• surgical hormonal therapy for sexual hormone-responsive cancers :
• ovariectomy for breast carcinoma
• orchiectomy for prostate adenocarcinoma and male breast carcinoma
• adrenalectomy for breast carcinoma
• hypophysectomy for  for breast carcinoma
• urinary surgery
• endourology : the branch of urologic surgery concerned with closed procedures for visualizing or manipulating the urinary tract; it may refer to procedures involving any part of the urinary tract or may be limited to procedures involving only the kidney or ureter.
• kidney surgery
• renal decapsulation, capsulectomy or decortication / nephrocapsectomy : surgical removal of the capsule of the kidney
• nephrectomy : excision of a kidney.
• abdominal or anterior nephrectomy : nephrectomy through an incision in the abdominal wall.
• lumbar or posterior nephrectomy : nephrectomy through an incision in the loin.
• paraperitoneal nephrectomy : the surgical removal of a kidney by a cut through the side along the twelfth rib.
• radical nephrectomy :  removal of a kidney with its fascia after prior ligation of the renal artery and vein, as well as removal of the adjacent adrenal gland and all lymph nodes in the region; done for treatment of renal cell carcinoma.
• heminephrectomy : excision of a portion of a kidney.
• nephrocystanastomosis : the surgical formation of a communication between the kidney and the urinary bladder.
• nephrolithotomy : the removal of renal calculi by incision through the kidney.
• percutaneous nephrolithotomy (PCNL) : removal of renal calculi using an endoscope that penetrates the skin.
• nephropyelolithotomy : removal of renal calculi from the renal pelvis by an incision through the kidney substance.
• nephrostolithotomy : removal of renal calculi through a nephrostomy tube inserted through the abdominal wall into the renal pelvis
• nephropyeloplasty : plastic operation on the pelvis of the kidney.
• nephrorrhaphy : the operation of suturing the kidney.
• nephrostomy : the creation of a fistula leading directly into the pelvis of the kidney.
• percutaneous nephrostomy : insertion of a catheter through the skin and into the renal pelvis under the guidance of fluorography or ultrasonography; performed for relief of supravesical obstruction and to gain access to the upper urinary tract for a variety of procedures, such as dilation of strictures or removal of calculi.
• nephropexy : the fixation or suspension of a floating kidney.
• nephrotomy : a surgical incision into the kidney.
• abdominal nephrotomy : nephrotomy performed through an incision into the abdomen.
• anatrophic nephrotomy : incision into the kidney between its vascular segments, to minimize bleeding and parenchymal injury and to prevent atrophy.
• lumbar nephrotomy : nephrotomy performed through an incision into the loin.
• nephroureterectomy : excision of a kidney and a whole or part of the ureter.
• heminephroureterectomy : excision of a portion of a kidney and ureter.
• nephroureterocystectomy : excision of the kidney, ureter, and a portion of the bladder wall.
• pyelolithotomy : the operation of excising a renal calculus from the pelvis of the kidney
• pyeloplasty : a plastic operation on the pelvis of the kidney
• pyelostomy : surgical formation of an opening into the renal pelvis to temporarily divert the urine from the ureter.
• pyelotomy : incision of the pelvis of the kidney
• pyeloureterolysis : the surgical freeing of fibrous bands or adhesions near the junction of the renal pelvis and ureter.
• abdomino-Peña pull-through procedure : for urinary continence used in treatment of cloacal exstrophy
• Mitrofanoff's procedure : for urinary continence, used in treatment of cloacal exstrophy
• ureter surgery
• Kelly's sign : if the ureter is teased with an artery forceps, it will contract like a snake or worm.
• Maydl's operation : insertion of the ureters into the rectum for exstrophy of the bladder; of historical interest.
• pyeloileocutaneous anastomosis : direct connection of the renal pelvis to an isolated loop of the ileum, which is then anchored to the abdominal wall at the stoma, to drain exteriorly.
• ureteroileocutaneous anastomosis : connection of the transected ureter to an isolated loop of the ileum, which is then anchored to the abdominal wall at the stoma, to drain exteriorly.
• transureteroureteral anastomosis : the operation of connecting one ureter to the ureter on the opposite side.
• ureteroureteral anastomosis : the operation of joining portions of the same ureter.
• LeDuc technique : a method for anastomosing the ureters to the bowel or to a urinary reservoir; the ureter is brought through the bowel wall and the end is spatulated and sutured to a T -shaped incision in the bowel mucosa
• Bricker's operation : the surgical creation of an ileal conduit with a flat stoma for the collection of urine; the flat contour is achieved by suturing the ileal mucosa to the skin^ref.
• ileal conduit (orthotopic neobladder) : the surgical anastomosis of the ureters to one end of a detached segment of ileum, the other end being used to form a stoma on the abdominal wall
• Bigelow's operation / lithotripsy :
• Rovsing's procedure : surgical unroofing of renal cysts followed by aspiration of their fluid.
• Young-Dees-Leadbetter procedure : repositioning of the ureters to a more superior position on the bladder and construction of a new bladder neck sphincter using the trigonal muscle; done for the treatment of urinary incontinence
• ureterolysis : the operation of freeing the ureter from adhesions.
• ureterorrhaphy : suture of a ureter.
• ureterectomy : the surgical removal of a ureter or of a part of it
• ureterocelectomy : excision of a ureterocele
• ureteromeatotomy : incision of the opening of the ureter in the bladder wall.
• ureterostomy : surgical formation of a fistula through which a ureter may discharge its contents.
• ureterovesicostomy : the operation of reimplanting the ureter at a different site in the bladder wall.
• Grégoir-Lich technique : a ureteral implantation technique in which a submucosal tunnel is created within the bladder and a new opening is created in the muscular wall of the bladder. Extramucosal bladder incision => mucomucosal anastomosis of ureter and bladder => positioning of ureter along the bladder incision => closure of muscle layers above the ureter to create an antireflux mechanism


• cutaneous ureterostomy / ureterocutaneostomy (UCS) : the operation of bringing the ureter to the skin through an incision in the iliac region, permitting drainage of urine directly to the exterior of the body
• ureteroneocystostomy / ureterocystostomy / ureterocystoneostomy / ureterocystanastomosis : surgical transplantation of the ureter to a different site in the bladder
• ureterocutaneostomy : surgical creation of a ureteral opening on the skin, permitting drainage of urine directly to the exterior of the body
• ureteroenterostomy : surgical creation of an opening between a ureter and the intestine (1 only collector).
• ureteroileostomy : anastomosis of the ureters to an isolated loop of the ileum, drained through a stoma on the abdominal wall.
• ureterocolostomy : anastomosis of a ureter to the colon
• ureterosigmoidostomy : the operation of implanting the ureter into the sigmoid colon
• ureteroproctostomy / ureterorectostomy / ureterorectoneostomy : surgical creation of an anastomosis between a ureter and the lower rectum to use continence of rectal sphincter (higher risk of metabolic acidosis and infections)
• ureteropyeloneostomy / ureteroneopyelostomy / ureteropelvioneostomy / ureteropyelonephrostomy / pelvioneostomy : surgical formation of a new passage from the pelvis of a kidney to the ureter
• ureterotrigonoenterostomy : implantation into the intestine of the ureter with the part of the bladder wall surrounding its termination.
• ureterotrigonosigmoidostomy : implantation of the ureter with part of the bladder wall into the sigmoid colon.
• ureteroureterostomy / van Hook's operation : end-to-end anastomosis of the two portions of a transected ureter; see also transureteroureterostomy.
• ureteronephrectomy : extirpation of a kidney and its ureter
• ureteroplasty : plastic surgery of a ureter.
• ureteropelvioplasty : surgical reconstruction of the junction of the ureter and renal pelvis.
• Culp-DeWeerd ureteropelvioplasty : ureteropelvioplasty in which a spiral pelvic flap is turned down and incorporated into the adjacent ureter.
• Foley Y - V ureteropelvioplasty : an operation using a pelvic flap for correction of obstructive, congenital high insertion of the ureter into the renal pelvis.
• Scardino-Prince ureteropelvioplasty : ureteropelvioplasty in which a vertical pelvic flap is turned down and incorporated into the adjacent ureter
• ureteropyeloplasty / pyeloureteroplasty : any plastic operation on the ureter and renal pelvis
• ureterovesicoplasty : plastic repair of the ureterovesical junction for correction of ureterovesical reflux or obstruction.
• colpocystoureterocystotomy : the operation of exposing the ureteral orifices by incising the walls of the bladder and vagina.
• bladder surgery
• cystopexy to correct cystocoele
• cystectomy : resection of the bladder.
• partial cystectomy
• radical cystectomy : surgical treatment of invasive bladder cancers by removal of the bladder with its peritoneal covering, the lower ureters, bilateral pelvic lymph nodes, and surrounding organs and structures
• in females (anterior pelvic exenteration) : excision en masse of the bladder, lower ureters, and first third of vagina, adnexa (uterus, fallopian tubes, ovaries), pelvic lymph nodes, and pelvic peritoneum, with ureterocolostomy or ileal conduit
• in males (radical cystoprostatectomy) the prostate, seminal vesicles, pelvic vas deferens and its ampulla, and sometimes part or all of the urethra are removed.
• transurethral resection of bladder tumor (TURBT) : removal of a tumor of the urinary bladder by means of a cystoscope passed through the urethra


• cystidolaparotomy / cystidoceliotomy : incision of the bladder through the abdominal wall
• cystidotrachelotomy : incision of the neck of the bladder
• cystocolostomy : the surgical creation of a permanent passage from the bladder to the colon
• cystoelytroplasty : surgical repair of vesicovaginal injuries
• cystolithectomy / cystolithotomy  : the removal of a urinary calculus by cutting into the urinary bladder. The term has been used erroneously for excision of a gallstone from the gallbladder.
• cystolithiasis : the development of calculi in the urinary bladder.
• cystoplasty : any plastic or reconstructive operation on the bladder
• augmentation cystoplasty : enlargement of the bladder by grafting to it a detached segment of intestine (ileum, cecum, or sigmoid).
• intestinocystoplasty
• sigmoidocolocystoplasty / sigmoid cystoplasty : cystoplasty in which a portion of the sigmoid colon is used to reconstruct or augment the bladder.
• cystoplegia / cystoparalysis : paralysis of the bladder
• cystoproctostomy / cystorectostomy : the surgical creation of a communication between the urinary bladder and rectum
• cystoprostatectomy : surgical removal of the urinary bladder and prostate gland.
• radical cystoprostatectomy : radical cystectomy in a male.
• cystorrhaphy : the operation of suturing the bladder.
• cystostomy / vesicostomy : the formation of an opening into the bladder.
• suprapubic cystostomy : surgical diversion of the urethra to an opening in the skin above the symphysis pubis for bladder drainage in cases of urethral stricture.
• Petersen's bag : an inflatable rubber bag inserted into the rectum so as to elevate the bladder in the operation of suprapubic cystotomy.
• tubeless cystostomy / cutaneous vesicostomy : surgical anastomosis of the bladder mucosa to an opening in the skin below the umbilicus, creating a stoma for bladder drainage; done in infants as a temporary alternative to suprapubic cystostomy.
• cystotomy / vesicotomy : surgical incision of the urinary bladder
• Franco's operation / suprapubic cystotomy : the operation of cutting into the bladder by an incision just above the pubic symphysis.
• colpocystotomy : incision of the bladder through the vaginal wall
• proctocystotomy : incision into the bladder from the rectum
• cystotrachelotomy : surgical incision of the neck of the bladder.
• Emmet's operation : surgical creation of a vesicovaginal fistula to secure drainage of the bladder in cystitis.
• vesicofixation : the surgical fixation of the urinary bladder; cystopexy
• vesicoclysis : the injection of a fluid into the urinary bladder.
• Kelly's operation : an operation for correction of stress incontinence in women; the site of the internal urinary sphincter is identified with a balloon catheter and the connective tissue between the vagina and the urethra and the floor of the bladder are sutured to form a wide shelf of firm tissue supporting the urethra and bladder.
• Marshall-Marchetti-Krantz operation : an operation for the correction of stress incontinence, the anterior portion of the urethra, vesical neck, and bladder being sutured to the posterior surface of the pubic bone.
• Millin-Read operation : an operation for the correction of stress incontinence employing the suprapubic approach.
• Pereyra operation : a surgical technique for the correction of stress incontinence: a loop of suture or other material is inserted through the paraurethral tissue near the bladder neck and attached to the abdominal fascia in order to elevate the bladder.
• trigonectomy : excision of the base of the bladder (trigonum vesicae).
• urethra surgery
• Lowsley's operation : an operation for repair of simple epispadias, consisting in closing the glandular cleft urethra, splitting the glans, and burying the repaired urethra deep in the soft tissue so that the orifice will be positioned at the normal site.
• Young's operation : an operation for penile epispadias, with formation of a new urethral tube
• MAGPI procedure : surgical correction of hypospadias with chordee by meatoplasty and glanuloplasty to advance the meatal orifice distally
• urethropexy : surgical fixation of the urethra to the overlying symphysis pubis and fascia of the rectus abdominis muscle, in correction of stress incontinence in the female
• urethrocystopexy : surgical fixation of the urethrovesical junction, and the area of the bladder just above it, to the back of the pubic bones, for relief of stress incontinence.
• urethroplasty : plastic surgery of the urethra.
• Dennis Browne operation : a urethroplasty for hypospadias repair, in which an intact strip of epithelium is left on the ventral surface of the penis to form the roof of the urethra, and the floor of the urethra is formed by epithelialization from the lateral wound margins.
• Cecil's operation : a 2-stage urethroplasty for hypospadias repair, with construction of a new urethral segment buried in the scrotum, followed by separation of the new urethra from the scrotum.  2. a 3-stage urethroplasty for repair of urethral stricture, with excision of the strictured area through an incision on the ventral surface of the penis, followed by the steps of the operation used for hypospadias repair.
• Duplay's operation : a method of urethroplasty for repair of hypospadias, employing a buried skin strip.
• urethrorrhaphy : suture of the urethra
• urethrostomy : surgical formation of a permanent opening of the urethra at the perineal surface
• urethrotomy : incision of the urethra for relief of stricture.
• external urethrotomy : incision of the urethra through the perineum.
• internal urethrotomy : incision of the urethra from within, either blindly or with an instrument that permits direct visualization.
• urethrectomy : the surgical removal of the urethra or a part of it.
• meatoplasty : plastic surgery of a urinary meatus
• meatorrhaphy : suture of the cut end of the urethra to the glans penis after incision for enlarging the meatus
• meatotomy : incision of the urinary meatus in order to enlarge it.
• gastrocystoplasty : cystoplasty in which a portion of the stomach is used to replace or increase the size of the urinary bladder.
Web resources : British Association of Urological Surgeons (BAUS)
• pelvic exenteration : excision of the organs and adjacent structures of the pelvis
• posterior pelvic exenteration : excision en masse of the pelvic colon, uterus, vagina, and adnexa, with or without pelvic lymph node excision, the lower urinary tract being undisturbed
• total pelvic exenteration : excision en masse of the bladder, lower ureters, vagina, uterus, adnexa, and the pelvic and lower sigmoid colon, with excision of the pelvic lymph nodes, removal of all the pelvic peritoneum, and replantation of the ureters into an isolated ileal segment
• hemicorporectomy : surgical removal of the lower part of the body through the lumbar region, including the bony pelvis, legs, genitalia, and pelvic contents such as the anus and lower rectum.
gridiron abdomen.
• orthopedic surgery : that branch of surgery which deals with the correction of deformities of the musculoskeletal system
• bone surgery
• Kazanjian's operation : a technique of surgical extension of the buccal vestibular sulcus of edentulous ridges to increase their height and to improve denture retention.  2. the use of extraskeletal fixation for support in compound zygomaticomaxillary fractures: a small hole is drilled through the infraorbital rim, and a stainless steel wire is inserted with both ends brought out through the wound, where they are twisted together into a loop or hook. Rubber band traction between the suspension wire and an outrigger on a head cap provides support for the zygomatic fragments.
• Keller operation : sagittal resection of the medial prominence of the first metatarsal head and excision of the base of the proximal phalanx of the great toe; done for hallux valgus.
• Kocher's operation : a method of excising the ankle joint by a cut below the outer malleolus, division of the peroneal tendons, removal of the diseased tissues, and suture of the divided tendons.  2. a method of reducing a subcoracoid dislocation of the humerus.  3. excision of the tongue through an incision extending from the symphysis of the jaw to the hyoid bone and thence to the mastoid process.  4. see under maneuver.  5. a method of pylorectomy.
• Lapidus operation : a procedure for correction of hallux valgus, involving wedge resection and fusion of the innermost cuneometatarsal joint and establishment of a bridge between the bases of the first and second metatarsals.
• Hoffa-Lorenz's operation : an operation for congenital dislocation of the hip, consisting in reduction of the dislocation, and keeping the head of the femur fixed against the rudimentary acetabulum until a socket is formed.
• McBride operation : resection of the medial prominence of the first metatarsal head, medial capsulorrhaphy, resection of the fibular sesamoid, and transfer of the adductor tendon to the neck of the first metatarsal; done for hallux valgus.
• Mitchell operation : a procedure for correction of hallux valgus, involving distal osteotomy of the first metatarsal.
• Ober's operation : medial subtalar syndesmotomy for clubfoot.
• Péan's operation : hip joint amputation in which the vessels are ligated as the operation goes on.
• Phelps' operation : an open and direct incision through the sole and inner side of the foot, done for talipes.
• Phemister operation : use of an onlay graft of cancellous bone without internal fixation, for treatment of a stable but ununited fracture.
• Silver operation : resection of the medial prominence of the first metatarsal head, medial capsulorrhaphy of the first metatarsophalangeal joint, and sectioning of the adductor tendon; done for hallux valgus.
• Steindler operation : surgical correction of pes cavus by stripping muscle and fascia from the plantar calcaneal surface.
• Whitman's operation : an operation for arthroplasty of the hip joint
• Whitman's operation : a method of astragalectomy.
• Mikulicz's operation : removal of the sternocleidomastoid muscle for torticollis.
• Vladimiroff operation : tarsectomy in which the heel, os calcis, and astragalus are removed, the articular surfaces of the tibia, fibula, cuboid, and scaphoid are excised, and the foot brought into line with the leg
• sacrotomy : the operation of cutting into the lower end of the sacrum
• sacrectomy : excision or resection of the sacrum
• skeletal fixation : immobilization of the ends of a fractured boneby metal wires or plates applied
• on the body surface (external skeletal fixation)
• external pin fixation : in oral surgery, a method for stabilizing fractures by means of pins drilled into the bony parts through the overlying skin and connected by metal bars.
• biphase external pin fixation : external pin fixation in which the rigid metal bar connector is replaced with an acrylic bar adapted at the time of the reduction
• internal or intraosseous fixation : the open reduction and stabilization of fractured bony parts by direct fixation to one another with surgical wires, screws, pins, and plates.
• maxillomandibular fixation : the fixation of fractures of the maxilla or mandible in a functional relationship with the opposing dental arch, through the use of elastics, wire ligatures, arch bars, or other splints.
• elastic band fixation : the stabilization of fractured segments of the jaws by means of intermaxillary elastic bands applied to splints or appliances.
• nasomandibular fixation : mandibular immobilization, especially for edentulous jaws, using maxillomandibular splints; a circummandibular wire is connected with an intraoral interosseous wire passed through a hole drilled into the anterior nasal spine of the maxilla
• closed reduction : the manipulative reduction of a fracture or dislocation without incision.
• open reduction : reduction of a fracture or dislocation after incision into the site
• countertraction : traction opposed to another traction; employed in the reduction of bone fractures.


• crutch : a device of wood or metal, ordinarily long enough to reach from the armpit to the ground, with a concave surface fitting under the arm and a cross bar for the hand, used for supporting the weight of the body
• axillary crutch (fig. A) : any of several types of crutches that have a long, rigid vertical structure, a short padded horizontal bar that fits under the axilla, and another short bar at waist level that is used as a hand grip.
• forearm crutch / English cane (fig. B) : a crutch whose top is at the level of the forearm, with a hand bar as well as a cuff that goes around the forearm to increase stability.
• Lofstrand crutch : the most common kind of forearm crutch, consisting of an aluminum tube that bends slightly posteriorly just above the hand grip.
• Canadian or triceps crutch : a crutch consisting of 2 uprights extending halfway between the elbow and shoulder, with a cross piece for the hand and a curved upper arm part against which the subject leans the upper arm

• cane : a wooden stick or metal rod used for support in walking.
• adjustable cane : a cane whose length can be easily altered.
• tripod cane : one similar to a quadripod cane except that it forks to provide a three-legged, triangular base of support.
• quadruped or quadripod cane: one adapted for increased stability by forking to provide a four-legged rectangular base of support.
• Buck's extension : the extension of a fractured leg by weights, the foot of the bed being raised so that the body makes counterextension.
• nail extension : extension exerted on the distal fragment of a fractured bone by means of a nail or pin driven into the fragment.
• osteotomy : the surgical cutting of a bone.
• angulation osteotomy : in midhumeral amputation, the bending of a small terminal of the humerus at a right angle to the bone shaft so as to provide a projection that locks the prosthesis to the bone.
• block osteotomy : osteotomy in which a section of bone is removed.
• cuneiform osteotomy : the removal of a wedge of bone.
• cup-and-ball osteotomy : osteotomy in which the distal fragment is pointed and the proximal fragment is recessed.
• displacement osteotomy : surgical division of a bone and shifting of the divided ends to change the alignment of the bone or to alter weight-bearing stresses.
• Le Fort osteotomy / total maxillary osteotomy : transverse sectioning and repositioning of the maxilla; the incision for each of the three types (Le Fort I, II, and III o's) is placed along the line defined by the corresponding Le Fort fracture
• linear osteotomy : the sawing or linear cutting of a bone.
• Lorenz's osteotomy : osteotomy of the neck of the femur by a V -shaped cutting of the femur so as to prevent displacement of the shaft.
• pelvic osteotomy / pubiotomy : surgical separation of the pubic bone lateral to the median line.
• innominate osteotomy : pelvic osteotomy to deepen the acetabulum in congenital dislocation of the hip.
• inverted L osteotomy : a type of osteotomy performed on the mandible to correct prognathism, the cut being an inverted L shape made in the ramus just below the condyle.
• sagittal split osteotomy / sagittal ramus osteotomy / sagittal splitting of mandible : intraoral osteotomy of the ascending mandibular ramus and posterior body of the mandible in the sagittal plane for correction of prognathism, retrognathism, or open bite; an alternative procedure confines the split to the body of the mandible.
• sandwich osteotomy : a surgical technique for augmenting an atrophic mandible; it is similar to a visor osteotomy but the split is a horizontal one confined between the mental foramina so that only the anterior portion of the cranial fragment is lifted upward.
• vertical ramus osteotomy : a type of osteotomy performed to correct prognathism; the ramus is resected in a vertical line proceeding from the sigmoid notch to the angle area of the lower border of the mandible.
• visor osteotomy : a surgical technique for augmenting an atrophic mandible, performed by splitting the mandible sagittally and sliding the cranial fragment upward, then supporting the structure with interposed grafts
• visor/sandwich osteotomy : a combination of the visor and sandwich osteotomies in which the cut is in the vertical plane posterior to the mental foramina and at a 45° angle in the anterior region.
• ostearthrotomy / osteoarthrotomy  : excision of an articular end of a bone.
• ostectomy / osteectomy : the excision of a bone or a portion of a bone.
• osteoclasis : the surgical fracture or refracture of bones
• osteoplasty : plastic surgery of the bones.
• osteosuture / osteorrhaphy : the suturing or wiring of bones
• osteosynthesis : surgical fastening of the ends of a fractured bone by sutures, rings, plates, or other mechanical means.
• Fulkerson's procedure : a modification of Maquet's procedure in which the tibial tubercle pedicle is shifted medially as well as elevated and held in place with a screw.
• Maquet's procedure : anterior displacement of the tibial tubercle by creation of a long pedicle of tibial tubercle, which is elevated and held in place by a bone graft taken from the iliac crest; done for relief of severe patellofemoral pain.
• bone resection / excision / ectomy : removal of a portion or all of a bone
• Girdlestone resection :  removal of the femoral head and neck in cases of severe hip infection.
• autotransplantation :  (donor : fibula or iliac wing)
• Adams' operation :  subcutaneous intracapsular division of the neck of the femur for ankylosis of the hip.  2. subcutaneous division of the palmar fascia at various points for Dupuytren's contracture.  3. excision of a wedge-shaped piece from the eyelid for relief of ectropion.
• Albee-Delbet operation : an operation for fracture of the neck of the femur, done by drilling a hole through the trochanter and the neck and head of the femur and inserting a bone peg in this hole.
• Albert's operation : excision of the knee to secure ankylosis for the cure of flail joint.
• Akin operation : resection of the medial prominence of the first metatarsal head and cuneiform osteotomy of the proximal phalanx of the great toe, done for hallux valgus.
• Albee's operation : operation for ankylosis of the hip, consisting of cutting off the upper surface of the head of the femur and freshening a corresponding point on the acetabulum, and permitting the two freshened surfaces to rest in contact.
• Barker's operation : an excision of the hip joint by an anterior cut.  2. a special method of excising the astragalus by an incision extending from just above the external malleolus forward and inward to the dorsum of the foot.
• Barsky's operation : an operation for repair of a cleft hand with a missing central ray and a deep central V-shaped cleft, consisting in closing the cleft, bringing the ring and index fingers closer together, and correcting the associated syndactyly, if present.
• Barton's operation : an operation for ankylosis consisting of sawing through the bone and removing a V-shaped piece.
• Buck's operation : cuneiform excision of the patella and the ends of tibia and fibula.
• Colonna's operation : a reconstruction operation for intracapsular fracture of the femoral neck.  2. a common type of capsular arthroplasty of the hip.
• Girdlestone operation or resection : removal of the femoral head and neck in cases of severe hip infection.
• Heath's operation : division of the ascending rami of the lower jaw with a saw for ankylosis, performed within the oral cavity; rarely done.
• Hibbs' operation : a spinal fusion operation done by fracturing the spinous processes of the vertebrae and pressing the tip of each downward to rest in the denuded area caused by the fracture of its elbow below.
• Gillies operation : a technique for reducing fractures of the zygoma and zygomatic arch through an incision in the temporal region above the hairline.
• amputation : the removal of a limb or other appendage or outgrowth of the body
• above-elbow amputation : amputation of the upper limb between the elbow and the shoulder.
• below-elbow amputation : amputation of the upper limb between the wrist and the elbow.
• transfemoral or above-knee (A-K) amputation : amputation of the leg between the knee and the hip; the femur may be divided in the supracondylar region (long above-knee amputation), at midthigh, or high on the thigh
• Kirk's amputation : a tenoplastic above-knee amputation done just above the femoral condyles, with the tendon of the quadriceps femoris muscle sutured over the end of the divided femur.
• transtibial or below-knee (B-K) amputation : amputation of the lower leg between the ankle and the knee; called long below-knee when in the distal third of the tibia and short below-knee when in the proximal third of the tibia
• Guyon's amputation : below-knee amputation just above the malleoli
• Alanson's amputation : circular amputation, the stump being shaped like a hollow cone.
• Alouette's amputation or operation : amputation at the hip, with a semicircular outer flap to the great trochanter and a large internal flap from within outward
• Bunge's aperiosteal amputation : amputation with complete removal of the periosteum from the end of the stump of the bone
• Carden's amputation : a single flap above-knee amputation done just above the knee.
• central amputation : one in which the scar is situated at or near the center of the stump.
• Chopart's mediotarsal amputation or operation : amputation of the foot, with the calcaneus, talus, and other parts of the tarsus being retained
• Tripier's amputation : one like Chopart's, except that a part of the tarsus is removed.
• circular amputation : one performed by means of a single flap and by a circular cut in a direction vertical to the long axis of a limb.
• closed or flap amputation : one in which flaps are made from the skin and subcutaneous tissue and sutured over the end of the bone
• coat-sleeve amputation : a circular amputation, with a single skin flap made very long, the end being closed with a tape.
• amputation in contiguity : an amputation at a joint.
• amputation in continuity : an amputation elsewhere than at a joint.
• cutaneous amputation : amputation in which the flaps are composed entirely of skin.
• double-flap amputation : one in which 2 flaps are formed.
• disarticulation / exarticulation : amputation or separation at a joint
• shoulder disarticulation : amputation of the upper limb through the shoulder joint.
• Dupuytren's or Lisfranc's amputation or operation : amputation of the upper limb through the shoulder joint
• Larrey's amputation or operation : shoulder disarticulation with an incision extending from the acromion about three inches down the arm, splitting the deltoid muscle, and from this point going around the arm to the center of the axilla
• elbow disarticulation : amputation of the upper limb through the elbow joint.
• wrist disarticulation : amputation of the hand through the wrist joint.
• hip disarticulation : amputation of the lower limb through the hip joint.
• Béclard's amputation : hip disarticulation with cutting of the posterior flap first.
• knee disarticulation : amputation of the lower limb through the knee joint.
• Callander's amputation : a tenoplastic knee disarticulation with long anterior and posterior flaps, the patella being removed to leave a fossa for the end of the divided femur.
• Gritti's amputation or operation : knee disarticulation using the patella as an osteoplastic flap over the end of the femur
• Gritti-Stokes amputation or operation : a modification of Gritti's amputation, using an oval anterior flap
• Ricard's amputation : amputation of the foot with disarticulation of the tibia from the calcaneus, astragalectomy, and the placing of the calcaneus in the mortise between the tibia and fibula.
• ankle disarticulation : amputation of the foot at the ankle joint
• Syme's amputation or operation : ankle disarticulation with removal of both malleoli
• Mackenzie's amputation : amputation like that of Syme except that the flap is taken from the inner side of the ankle.
• Hey's amputation or operation : disarticulation of the tarsus from the metatarsus with removal of a part of the medial cuneiform bone
• eccentric amputation : one in which the scar is not at the center of the stump.
• elliptic amputation : one in which the cut has an elliptic outline on account of the oblique direction of the incision.
• Farabeuf's amputation : amputation of the leg, with a large external flap.
• chop, flapless, open, or guillotine amputation : rapid amputation of a limb by a circular sweep of the knife and a cut of the saw, the entire cross-section being left open for dressing; done when primary closure of the stump is contraindicated, owing to the possibility of recurrent or developing infection
• Jaboulay's hindquarter amputation or operation / interpelviabdominal amputation / hemipelvectomy : amputation of a lower limb through the sacroiliac joint
• hindquarter, interilioabdominal or interinnominoabdominal amputation : amputation of an entire lower limb, including the whole or part of the hip bone
• Berger's operation / forequarter or interscapulothoracic amputation: amputation of the upper extremity, including the scapula and the clavicle
• kineplastic, cinematic or cineplastic amputation / kineplasty : plastic amputation; amputation in which the stump is so formed as to be utilized for motor purposes.
• Langenbeck's amputation : amputation in which the flaps are cut from without inward.
• linear amputation : amputation by a simple straight division of all the tissues.
• Lisfranc's amputation or operation : amputation of the foot between the tarsus and the metatarsus
• Maisonneuve's amputation : amputation by breaking the bone, followed by cutting of the soft parts.
• major amputation : amputation of a leg above the ankle or of an arm above the wrist.
• minor amputation : amputation of a small part, as of a finger or toe.
• mixed amputation : that which is performed by a combination of the circular and flap methods.
• musculocutaneous amputation : one in which the flap consists of muscle and skin.
• osteoplastic amputation : one in which the 2 severed surfaces of bone are brought into contact so as to unite.
• Bier's amputation or operation : osteoplastic amputation of the leg with a bone flap cut out of the tibia and fibula above the stump
• Vladimiroff-Mikulicz amputation : a type of osteoplastic amputation of the foot with incision of the calcaneus and talus.
• oblique or oval amputation / loxotomy : one in which the incision consists of two reversed spirals
• phalangophalangeal amputation : amputation of a digit at a phalangeal joint.
• Pirogoff's amputation : amputation of the foot at the ankle, part of the calcaneus being left in the lower end of the stump.
• Le Fort's amputation : a modification of Pirogoff's amputation in which the calcaneus is sawed through horizontally instead of vertically.
• Hancock's amputation or operation : a modification of Pirogoff's amputation, a part of the astragalus (talus) being retained in the flap, the lower surface being sawed off, and the cut surface of the calcaneus being brought into contact with it
• ray amputation : amputation of a metacarpal or metatarsal and all the phalangeal segments distal to it.
• racket amputation : one in which there is a single longitudinal incision continuous below with a spiral incision on each side of the limb.
• rectangular amputation : one with a long and a short rectangular skin flap, as in Teale's amputation.
• Teale's amputation or operation : amputation with preservation of a long rectangular flap of muscle and integument on one side of the limb and a short rectangular flap on the other.
• spontaneous amputation : loss of a part which occurs without surgical intervention, as in leprosy, diabetes mellitus, and Buerger's disease.
• Malgaigne's subastragalar amputation : amputation of the foot, leaving the astragalus (talus) in the lower end of the stump
• periosteoplastic or subperiosteal amputation : one in which the cut end of the bone is covered with a flap of periosteum
• amputation by transfixion : one performed by thrusting a long knife through the limb and cutting the flaps from within outward.
• transmetatarsal amputation : amputation of the anterior part of the foot across the metatarsal bones.
• traumatic amputation : amputation of a part by accidental injury.
Indications : gangrene
• critical limb ischemia
• ecthyma gangrenosum / gangrenous ecthyma
• conical stump : a cone-shaped amputation stump produced as a result of undue retraction of the muscles
• hemilaminectomy : surgical removal of one side of the vertebral lamina.
• hemiphalangectomy : the excision of part of a digital phalanx.
• astragalectomy : excision of the astragalus (talus).
• phalangeal set : a surgical office procedure for correction of deformities of the lesser toes, involving incision to reach the bony joint and manipulation for proper positioning
• bunionectomy : excision of an abnormal prominence (bunion) on the mesial aspect of the first metatarsal head.
• metatarsectomy : excision or resection of the metatarsus
• joint surgery
• arthrotomy : surgical incision of a joint.
• synovectomy : excision of a synovial membrane, as of that lining the capsule of the knee joint, performed in treatment of rheumatoid arthritis of the knee, or of the synovial sheath of a tendon.
• radiation synovectomy / radioisotope synovectomy / synoviorthesis : irradiation of the synovium by intra-articular injection of radiocolloids to destroy inflamed synovial tissue.
• articular resection / excision / ectomy : removal of a portion or all of a joint
• arthrodesis / artificial ankylosis : the surgical fixation of a joint by a procedure designed to accomplish fusion of the joint surfaces by promoting the proliferation of bone cells
• Moberg arthrodesis : fusion of a finger joint with a small squared bone peg.
• triple arthrodesis : fusion of the subtalar, calcaneocuboid, and talonavicular joints, to provide lateral stability to the paralyzed foot
• arthroereisis / arthrorisis : operative limiting of the motion in a joint that is abnormally mobile from paralysis
• capsulotomy : the incision of a joint capsule
• capsulectomy / decapsulation : excision of a joint capsule.
• synchondrectomy : surgical excision of a synchondrosis, especially of the symphysis of the pubic bone
• synchondroseotomy / Trendelenburg's operation : an operation for exstrophy of the bladder done by cutting through the sacroiliac ligaments and forcibly drawing together the pelvic bones
• symphysiolysis : separation or slipping of symphyses, especially the symphysis pubis
• symphysiorrhaphy / symphyseorrhaphy  : suture of a divided symphysis
• symphysiotomy : the division of the fibrocartilage of the symphysis pubis, in order to facilitate delivery, by increasing the diameter of the pelvis
• fascia surgery
• fasciorrhaphy : suture of lacerated fascia.
• fasciotomy : surgical incision or transection of fascia.
• fasciectomy : excision of fascia.
• fasciodesis : the operation of suturing a fascia to skeletal attachment
• fasciaplasty : a plastic operation on fascia.
• tendon surgery
• tenorrhaphy / tenosuture : the union of a divided tendon by a suture.
• tenotomy / tendotomy / tenontotomy / tendon release : the surgical cutting of a tendon
• curb tenotomy : the operation of cutting an eye muscle in squint and inserting it farther back on the globe of the eye.
• tenodesis : tendon fixation; suturing of the end of a tendon to a bone
• tenolysis / tendolysis : the operation of freeing a tendon from adhesions
• tenoplasty / tendinoplasty / tendoplasty / tenontoplasty : plastic surgery of the tendons; operative repair of a defect in a tendon
• tendineal transposition : the operation of carrying a tendon from one situation to another without severing its connection entirely until it is united at its new location.
• periosteal implantation : surgical insertion of a normal tendon into the periosteum of a bone at the insertion of a paralyzed tendon, to take its place.
• ligamentsurgery
• syndesmectomy : excision or resection of a ligament
• syndesmopexy : the operative fixation of a dislocation by reattachment of the ligaments
• syndesmoplasty : plastic operation on a ligament
• syndesmorrhaphy : suture or repair of ligaments.
• syndesmotomy : the dissection or cutting of a ligament.
• muscle surgery
• myotenontoplasty / tenomyoplasty : a plastic operation involving tendon and muscle.
• myotomy : the cutting or dissection of a muscle or of muscular tissue.
• tenomyotomy : excision of a portion of tendon and muscle.
• myotenotomy : surgical division of the tendon of a muscle
• myoplasty : plastic surgery on muscle; an operation in which portions of partly detached muscle are utilized, especially in the field of defects or deformities.
• myorrhaphy / myosuture : suture of divided muscle
• immune system surgery
• tonsillectomy : surgical removal of a tonsil or tonsils
• lymphadenectomy / lymph node dissection : surgical excision of a lymph node or nodes; often accompanied by an adjective referring to which node is removed
• axillary lymph node dissection : surgical removal of axillary lymph nodes, done as part of radical mastectomy.
• retroperitoneal lymphadenectomy / retroperitoneal lymph node dissection (RPLND) : surgical removal of lymph nodes in the retroperitoneal space, usually because of cancer metastasis, such as from carcinomas of the genital organs in men

Complications (5-35%) :
• death (1%)
• ileus
• vascular damages
• urethral damages
• intestinal and pancreatic damages
• chylous ascitis
• lumbar postgangliar sympathetic fiber lesions => no contraction of bladder neck at ejaculation => anejaculation or retrograde ejaculation
• skin surgery
• Mohs' technique : a technique of microscopically controlled serial excision of skin cancers in which the tissue to be removed is first fixed in situ with zinc chloride paste (Mohs' chemosurgery), or in which only serial excisions of fresh tissue are used for microscopic analysis (Mohs' surgery)
• V-Y procedure : a method of repairing a skin defect in which a V-shaped flap is made proximal to the defect; the flap is transferred to the defect, and the secondary defect thus created is closed to produce a Y-shaped scar.
• Burow's operation : a method of excising triangles of skin at the base of the pedicle of a skin flap to facilitate advancement
• Charles' operation : treatment of elephantiasis and other types of massive lymphedema of the lower limb by excision of subcutaneous tissue followed by skin grafting.
• Thompson's operation : a formerly common treatment for elephantiasis and other types of massive lymphedema of the lower limb, consisting of excision of some subcutaneous tissue and burying of a dermal flap among the underlying muscles.
• Homans' operation : a formerly common treatment for elephantiasis and other types of massive edema of the lower limb, consisting of excision of subcutaneous tissue and redundant skin on the lateral and medial aspects.
• Kondoleon's operation : a formerly common treatment for elephantiasis and other types of lymphedema by the removal of strips of subcutaneous tissue; it was later modified as Homans' operation.
• Cotting's operation : operation for ingrowing toenail, consisting in cutting off the side of the toe down to and including the ingrowing edge of the nail.
• butterfly : a small piece of adhesive tape with broad, wing-shaped ends by means of which the edges of a superficial wound may be approximated.
• skin button : a connector or stretch of tubing covered with dacron velour fabric, designed to encourage tissue ingrowth where it passes through the skin.
• Baldy-Webster operation :
• inlay : 1. material, such as bone or skin, inserted into a tissue defect.  2. a dental restoration made outside of a tooth to correspond with the form of a prepared cavity and then cemented into the tooth.
• Esser's operation / epithelial inlay : a method of securing epithelialization of an unhealed deep wound. A mold of the wound cavity is taken and covered with a Thiersch graft of epidermis, the whole being inserted into the wound cavity, and the edges then approximated with sutures. The mold is removed after ten days, leaving the cavity completely epithelialized
• onlay :1. a graft applied or laid on the surface of an organ or structure.  2. a cast metal restoration that overlays cusps, thus lending strength to the restored tooth.
• epithelial onlay : an epithelial graft, the edges of which are not completely approximated to the edges of the wound, thus permitting new epithelium to grow out around the margin
• onychectomy / declawing : excision of a nail or nail bed
• cosmetic operation : one intended to remove or correct a deformity in an esthetically acceptable manner.
• Dieffenbach's operation or amputation : plastic closure of triangular defects by displacing a quadrangular flap toward one side of the triangle.
• exploratory operation : surgical incision into an area of the body followed by inspection and palpation of organs and tissues to determine the cause of unexplained symptoms.
• flap operation : any operation involving the raising of a flap of tissue.  2. in periodontics, an operation to secure greater access to granulation tissue and osseous defects, consisting of detachment of the gingivae, the alveolar mucosa, and/or a portion of the palatal mucosa
• interval operation : an operation performed during the interval between 2 acute attacks of a disease, as in appendicitis.
• Kraske's operation : removal of the coccyx and part of the sacrum for access to a carcinoma of the rectum.
• open operation : an operation in which the tissues and organs are exposed to view through a surgical incision
• plastic operation : one in which the shape of a part or the character of its covering is altered by transplantation of tissue, etc.