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Department of Surgical Gastroenterology Jawaharlal Institute of Postgraduate Medical

Education & Research

Puducherry

India

Department Manual

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No. 0

Issue No. 1.0

SGE/JIPMER/DM/01 Date 01/01/2016

Prepared By Approved By Control Status

Private Circulation only

Page 1 of 94 Dr. Sandip Chandrasekar. A Dr. Biju Pottakkat

Assistant Professor Additional Professor

& Head

S.No Contents summary Page No

1 History 2

2 Department profile 3

3 Mission and vision 4

4 Department policies 5

5 Organogram 6

6 Faculty and staff details 7

7 Job description

Responsibilities and role of HOD

Responsibilities and role of consultant

Responsibilities and role of senior resident

Responsibilities and role of chief resident

9

10

11

13

8 Departmental administration 14

9 Policies on documentation 17

10 Services

Inpatient services

Outpatient services

19

24

11 Clinical programmes 31

12 Classification of diseases and conditions 34

13 Academic schedule and review meetings 36

14 Fire safety plan 40

15 Standard operating procedures 45

16 Information materials for patients 74

17 Inpatient and outpatient statistics 94

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No. 1

Issue No. 1.0






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History

The department of Surgical Gastroenterology has been conceptualized with three sanctioned

faculty posts - one professor/additional professor and two assistant professors and six senior

resident posts. The Department was started on 03/03/2010 with the joining of Dr V Ranjit Hari as

Assistant Professor. Dr. Vikram Kate, Professor of Surgery was appointed as faculty in charge. Dr

Vishnu Prasad, Additional Professor in General surgery, was deputed to the department in May

2010. Dr Biju Pottakkat, joined as Assistant Professor on 30/06/2011. Dr V Ranjit Hari

resigned from the post and was relieved on 14th June 2013. Dr R Kalayarasan joined as Assistant

P r o f e s s o r on 15/07/2013 on adhoc basis and later joined on regular basis on 26/11/2013.

Dr. Biju Pottakkat was promoted as Associate Professor on 01/07/2014 and later recruited as

Additional Professor on 09/09/2014. Dr Vikram Kate was relieved from the post of faculty in

charge and Dr Biju Pottakkat was appointed as Head of the department on 01/12/2014. Dr Sandip

Chandrasekar A joined as Assistant Professor on 02/02/2015 on adhoc basis.

Dr Alwin Gunaraj and Dr Senthil Kumar joined as senior residents on 01/06/2010.

MCh Surgical Gastroenterology course was commenced on 16/08/2011 with two sanctioned seats

per year. Dr Pradeep Joshi and Dr Salil Kumar Parida were the first MCh trainees of the

department. From January 2015, select ion of MCh candidates is taking place in two sessions -

one candidate each in January & July session. There are two junior residents working in the

department currently.

The outpatient clinics started during March 2010 and the inpatient facilities started with

eight general beds including two intensive care unit beds. Operation theatre services were

initiated from 02/06/2010. The dedicated surgical gastroenterology ward was begun with 16 beds on

01/08/2012. Dedicated ICU with six beds started functioning from 06/08/2012. Endoscopy

services were also initiated at the same time. Additional four general and four pay wards were included

to expand the services. Dedicated ostomy services were begun by 06/06/2013. Specialized dietary

services started on 01/11/2014. Obesity & metabolic surgery programme was started on 24/03/2015

and has been catering bariatric surgery services to those who could only dream of such

surgeries which involve high costs elsewhere. The department office commenced functioning

from 09-03-2011.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Department Profile

The department of surgical gastroenterology at JIPMER was established in the year 2010

with an aim provide advanced treatment, for training and extend research in the area of surgical

gastroenterology. The department aims to act as a leader in this domain in the country. It is

located in the JIPMER superspeciality block. It is a 32 bedded clinical unit with 3 full time

faculty, 6 resident doctors, 2 junior residents, 33 nursing staff and other supporting staff. The

department manages patients with complicated surgical problems in the GI tract and has

outpatient clinics, general and special wards, intensive care unit and operation theatre.

Superspeciality degree programme is running with two trainees per year. Regular residency

teaching programmes and continuing nursing programmes are ongoing. The department runs a

simulation laboratory, stoma clinic and a diet clinic. State of the art facilities and equipment’s are

available to fulfil the needs of complicated patients. Patient centered research in various arenas is

one of the foremost priorities of the department. The planned expansion in terms of new services,

programmes and infrastructure development are ongoing. Patients are treated at a highly

subsidized rate. Quality and safety of high order is maintained in patient care.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Mission and Vision

The department of surgical gastroenterology at JIPMER is envisioned to act as the leader

in the specialty in the country. The goal is to act as a department of excellence in patient care,

teaching and research.

Patient care- The aim is to develop innovative strategies in diagnosis and treatment of

common surgical diseases in the gastrointestinal tract which are common in southern India. The

core areas include cancer of liver, chronic pancreatitis, portal hypertension and cancer of

esophagus. The innovations include new concepts in etiology, re-look in to the existing definitions

and descript ions, novel diagnostic and evaluation algorithms and new management strategies.

Existing standard operating procedures for a particular disease will be relooked and modifications

will be suggested. Developing new concepts in equipment and instrument designs will be a priority.

Teaching- The aim is to include new systems of teaching in superspeciality training.

Endoscopy and percutaneous interventions will be part of the training. Simulation methods will be

used in a big way in training the procedures. Short and long term goals of training in MCh

curriculum will be specified with due emphasis to the recent advances. Specialty nursing at the

departmental level rather than nursing college level will be explored adopting the

methodology of ‘post qualification nursing training’ and the curriculum will be developed as

‘qualified in specialty’ concept.

Research- Lacunae in available scientific information in the specialty will be kept

as a prerequisite for new research initiatives in clinical management. Research in nursing care will

be given top priority. Research into systems and practices will be performed so as to create

new models for the country in care delivery.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Department policies

Quality and safety in patient care

Patient first approach in services

Inter area co-ordination

Equipment mutual sharing policy

Unit wise concept in department as well as area functioning

Transparency in concepts, plan and executions

Policy of internal audit of systems and practices

Faculty consultant system in individual patient care

Paper less policy, electronic transfer and storage policy for information and

communication

Ecofriendly policy

Promotion of research and development in all areas

Promotion of Hindi and Tamil among staff

Policy of staff wellness

Extra mile project – work beyond duty apart from duty

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Organogram

Head of Department Faculty: Assistant Professors (2)

Senior Residents (6)

Year I (2)

II (2)

III (2)

Junior residents (2)

Department In-charge ANS

Ward, OPD, OT, ICU,

Endoscopy Sister In-Charge

Stoma nurse

Staff nurses

Medico social worker

Dietician

Store keeper

Office assistant

Multi-tasking staff

Multipurpose worker

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Faculty and staff details

S. No Name Designation

1 Dr. Biju Pottakkat Additional Professor & Head

2 Dr. Kalayarasan. R Assistant professor

3 Dr. Sandip Chandrasekar. A Assistant professor

4 Dr. Gourav Kaushal Senior Resident

5 Dr. Gajendra Bhati Senior Resident

6 Dr. Shahana Gupta Senior Resident

7 Dr. Kapil Nagaraj. P Senior Resident

8 Dr. Santhosh Anand. K.S Senior Resident

9 Dr. Pavan Kumar. V Senior Resident

10 Mrs. Thilagavathi. T Assistant Nursing Superintendent

11 Mrs. Uma Prakash Babu Nursing sister in charge (OT)

12 Mrs. Sumathy. M Nursing sister in charge (OT)

13 Mr. Midhun K Staff nurse (OT)

14 Mrs. Priyankamol. V.C Staff nurse (OT)

15 Mr. Dhinakaran. S Staff nurse (OT)

16 Mr. Biji. K Staff nurse (OT)

17 Mrs. Mangaleshwari. M Staff nurse (OT)

18 Mr. Gopalakrishnan. G Staff nurse (OT)

19 Mrs. Kiruthigadevi. E Nursing sister in charge (ward)

20 Mrs. Rajakumari. R Nursing sister in charge (ward)

21 Mr. Shine. P.S Staff nurse (ward)

22 Mrs. Lanit ha. N.T Staff nurse (ward)

23 Mrs. Divya. K.S Staff nurse (ward)

24 Ms. Vyshnavi. M Staff nurse (ward)

25 Ms. Anju jose Staff nurse (ward)

26 Mrs. Neda. S Staff nurse (ward)

27 Mr. J. Muktatman Pandya Staff nurse (ward)

28 Ms. R. Yogaramya Staff nurse (ward)

29 Mrs. Indirani. M Nursing sister in charge (ICU)

30 Mrs. Aruna Sundari Devi. V.G Nursing sister in charge (ICU)

31 Mr. Mudavath R. Nayak Staff nurse (ICU)

32 Mr. Binny George Staff nurse (ICU)

33 Ms. Pavithra. M Staff nurse (ICU)

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34 Ms. Saranya. S Transplant co-ordinator

35 Ms. Nithyakalyani. C Staff nurse (ICU)

36 Mr. Sreevalsan. K Staff nurse (ICU)

37 Mr. B. Ramshankar Naik Staff nurse (ICU)

38 Ms. Tency George Staff nurse (ICU)

39 Mrs. Krishnaveni. N Staff nurse (ICU)

40 Mrs. Priya Grace Prakash Ostomy nurse

41 Mrs. Thilagavathi Sasikumar Ostomy nurse

42 Mrs. Vijaya Balasubramanian Nursing sister in charge (OPD)

43 Mrs. Punidavathi. A Nursing Sister in charge

(Endoscopy)

44 Mrs. Navamani Nursing Sister in charge

(Endoscopy)

45 Mrs. Priyadarsini. B Technician (Endoscopy)

46 Mrs. Amirthavalli. A Nursing sister in charge (Liver

Transplant)

47 Mrs. Dhilshath Begum. A Dietician

48 Mrs. Hena Melya Medical Social Worker

49 Mr. Sivasubarmanian. K.R Store keeper (Office)

50 Mr. Lalan Kumar Ray Multi-Tasking Staff

51 Mr. Ajeesh Sathyan Multi-Tasking Staff

52 Ms. Saranya. R Office Assistant

53 Mrs. Ramya Esther Rani Multi-Purpose Worker

54 Mr. Tamaraselvane Nursing Assistant

Department Manual

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JIPMER, PUDUCHERRY

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Job description Responsibilities & Role of HOD

1. To be responsible for the overall functioning of the department

2. To develop mission and vision for department after consulting with all staffs

3. To be an example by setting good standards in teaching, research and patient care

4. To take active steps in fostering cordial interpersonal relationships in the department and

ensuring that there is a smooth working relationship among all the members of the

department.

5. To co-ordinate teaching and research programmes of the department

6. To plan, conduct and monitor quality management systems of the department

7. To be known for humility, transparency and integrity

8. Conduct weekly departmental academic meetings and regular mortality and audit meetings.

9. Conduct monthly gastro pathology and gastro radiology meetings

10. Conduct monthly staff in-charge meetings

11. Conduct faculty meetings once in 3 months

12. Conduct MCh residents review meetings once in 6 months

13. Conduct annual departmental meeting

14. Interact with the administrators and external agencies on behalf of the department

15. Conduct model theory and practical exam for all MCh residents annually

16. Evolve direct ion plan and programme for the department

17. Attend inter departmental and other meetings with administration

18. Operate departmental funds

19. Interact with all groups of staff to ensure smooth functioning of department

20. Acquire, maintain and ensure optimal utilization of equipments

21. Plan and approve capital budget requests

22. Organize functions in department

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Job description

Responsibilities & role of Consultant

1. To be responsible for the care of patients admitted

2. Supervise, guide, teach and assist the trainee residents in the care of patients

3. Supervise and guide the residents in various procedure

4. Required to teach the residents on daily rounds

5. Carry out research work

6. Participate in the departmental training program and other training courses that will enhance

personal development, skills, knowledge and practice requirements

7. Co-ordinate and moderate seminars and journal clubs

8. To ensure implementation of the quality assurance programme &conducting clinical audits.

9. Formulating Guidelines & protocols

10. Support the HOD in all management responsibilities of the department

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Job description

Responsibilities & role of Senior Resident

The department admits one candidate biannually for the superspeciality degree, MCh in

Surgical Gastroenterology (SGE) through a national eligibility written test. They are considered as

temporary employees of the institute and are assigned as senior residents. They are involved in

dedicated full time surgical training, research and academic activities.

Surgical training is self-motivated and directed towards the needs of the community. They

are involved in identifying ailments relevant to GI tract and associated basic sciences. The

residents perform diagnostic and therapeutic GI endoscopic procedures, basic and advanced GI

(open and minimal access) operations independently and with the guidance of a senior surgeon.

They also undertake comprehensive GI perioperative intensive care management.

The trainees complete a dissertation during their curriculum. The conduct of this

dissertation is in accordance with institutional ethical and research monitoring committee. They

acquire basic knowledge of statistics to understand and critically evaluate published article. They

also prepare research paper for publication. Attending few lectures related to research, human

behavior studies, pharmaco-economics and non-linear mathematics are included in their training

period.

Senior residents study standard text books of GI surgery and keep updating themselves

with recent publications and journals. They have scheduled ongoing academic sessions including

monthly audit, case presentations, seminar in assigned topics and discussion of complex multi-

disciplinary cases. They attend national and international GI surgery conferences and update

themselves with recent advances in the field. Residents maintain record of important activities

during the training in the log book. They also have periodic assessment of their theory and

practical knowledge.

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In addition, the trainees are expected to demonstrate empathy and humane approach

towards patients and their families in accordance with the societal norms and expectations. They

also play the assigned role in the implementation of national health programme, effectively and

responsibly. They acquire the ability to organize and supervise the health care services

demonstrating adequate managerial skills in the clinic/hospital or the field situation. The

residents develop skills as a self-directed learner; recognize continuing educational needs; select

and use appropriate learning resources. They evolve as an effective leader of a health team

engaged in health care, research and training by the end of training programme.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Job description

Responsibilities & role of chief resident

The concept of chief residency was introduced in department of surgical gastroenterology,

so that residents will be well trained with responsibilities of a consultant and able to run a

department immediately after completion of their three year residency. Chief resident is the

resident who is in third and final year of his residency. He is virtual consultant bearing all

responsibilities of the department. He is key link between senior residents and the faculty. Chief

resident is expected to make all decisions regarding patient management and to discuss with

consultant as and when required. He is expected to involve in teaching of first and second year

senior resident and to coordinate all department and patient related work with them. Daily evening

ward round is conducted by chief resident which includes daily progress of patients presented to

him by senior residents. It includes comprehensive case by case discussion and formulation of

treatment plan on the basis of best available current evidence.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Departmental Administration

Surgical gastroenterology department office

Surgical Gastroenterology office shortly called as SGE Office is located at fourth floor of

SS Block IPD, Complex No.551. SGE Office complex comprising of ten rooms viz., offices of

the head of the department, three consultants, one female doctor, one male doctor, one

seminar room, one office staff room, one data room and one stores.

Department office functions as the link between the departmental and institute

administration. All the institute and external communications are channeled through the

office. SGE -Office plays the role of back end office administration for the main wing of

the department viz- outpatient clinics, in patient facility, intensive care unit, operation theatre

and endoscopy besides auxiliary wings like stoma clinic, diet clinic, skills lab & SGE office

itself. Office administration activit ies include human resource management (HRM) of 50

personnel (including doctors, nursing staff & para medical staff), continues medical

education (CME) to doctors & nurses, conducting symposiums & training Programmes, MCh

Courses & exams etc. Three national conferences, 07 regional level seminars, 20 departmental

level training programs are conducted. Office is manned by two multitasking staff and one

assistant.

The departmental store, manned by a storekeeper, provide logistics support to above

main & auxiliary wings of this department as regards to equipments, consumables, non-

consumables, information technology infrastructures, office contingencies, etc. Store activities

include forecasting of requirements, project ion, budgeting, procurement, and technical/price bids

evaluation, receipts of stores/ equipment, storing, distributions to its wings, maintenance contracts

for equipments etc. The department hosts equipment assets to the tune of Rs.10 crores and has

been procuring consumables/non-consumable products to the tune of one to two crores every

year. A separate procurement scheme is in place for those patients covered under insurance

scheme. Surgical gastroenterology store has a model smart bin location system and also taken a

lead of compiling a partial study report on JIPMER Inventory Management System called

“JIMS” which is likely to be integrated into upcoming hospital information system.

http://jipmer.edu.in/departments/surgical/surgical-gastroenterology/departmental-administration/

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Head of the department (HOD)

The department is headed by a senior faculty in the cadre of professor or additional

professor. Dr Biju Pottakkat is currently the head of the department. The head of the

department is acting as the chief executive officer of the department. As the staff in the

department are working in diverse do mains, each faculty is allotted various areas for

the betterment of services, teaching and research. Head of the department is responsible for

all the academic and administrative activities. Clinical services are designated to individual

consultants to ensure better patient care through individualized approach. Head of the department

is the chairman of all the academic programs and courses running in the department. He is the

convener of the MCh exit examination. All research proposals need clearance from the head of

the department. As the chairman of the department purchase committee, HOD has to generate all

the purchase requirement for the department and conduct the committee meetings. HOD is the

member of institute council and infect ion control committees. HOD chairs faculty meetings, in

charge nurses meetings and all other meetings in the department. Head of the department

initiates system changes taking inputs from ongoing feedbacks and discussions. Annual

performance of each employee will be assessed by HOD and will be forwarded to the director.

http://jipmer.edu.in/departments/surgical/surgical-gastroenterology/departmental-administration/

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Nursing administration

36 nurses are working in the department. Mrs. Thilagavathi. T, Assistant Nursing

Superintendent (ANS) heads the nursing services. Mrs E Kiruthiga Devi and Mrs Rajakumari R

are acting as nursing in charges in the ward and ten staff nurses are working under them. Mrs.

Indirani Mohanraj and Mrs Aruna Sundari Devi VG are heading the Intensive Care Unit (ICU)

and eight nurses are working there. Operation theatre services are supervised by Mrs Uma

Prakash Babu and Mrs M Sumathi and eight trained operation room nurses are involved in

operation theatre management. Mrs Vijaya Balasubramanian is heading the outpatient services

including ostomy care and diet clinic. Mrs. Amirthavalli is heading the liver transplant unit.

ANS oversees the systematic functioning and acts as a link with the institute

nursing administration. She acts as the representative of nursing services of the department

in all the hospital and departmental meetings. All the nursing training and academic programmes

are conceptualized and co-chaired by ANS. ANS is the in charge of nursing education and

nursing research. Interdepartmental co-operation in nursing services are ensured through ANS.

All the institute and hospital policies in patient and personnel care regarding quality

control, staff welfare etc. are communicated to all nurses through ANS. ANS convenes

nursing in charge meetings on a monthly basis and attend all the care review meetings.

Nursing in charges are responsible for overall wellbeing of the patients and ensures

smooth running of all services in their respective areas. They are actively involved in

education and training. All store indents from department store, central store, pharmacy,

laundry and linen section are handled by in charge nurses. Duty scheduling are effected in

respective service areas by in-charge nurses. In charge nurses are responsible for implementing

all the institute guidelines like infection control, workforce safety, JIPMER quality council

guidelines etc.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Policies on Documentation

Documentation in OP chart

Only faculty and senior residents can make entries in the OP chart

Whenever a patient is seen, the date, time and name of consultant is noted in the OP chart.

List out the chief complaints, personal, past and family history. The drugs the patient is on

is listed. Any new changes are marked

A relevant clinical examination is documented

A clinical impression and a plan of management is clearly written, along with the list of

tests ordered

Other details, if applicable that are documented are: Instructions or education given to

the patient, follow up instructions, health tips and diet instructions.

Documentation of assessments in IP

Visit summary is prepared by the senior resident as soon as the patient arrives. It is

typed and print out is kept in patient file

The chief complaint and clinical examination is documented and provisional diagnosis written

A plan of action is outlined based on entries made in the OP chart/discussion with the

consultant

Blood and other investigations sent are documented

Follow up of investigations and appropriate treatment is started and documented

Treatment, investigation & patient monitoring charts are prepared for ward & ICU separately

which furnishes the necessary progress of the patient.

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Policies on Documentation

Discharge summary

Contains the name of all consultants & residents in department with department contact

number

Contain name of treating consultant, SGE number, Diagnosis, date of admission, date of

operation and date of discharge

Should contain visit summary

Investigations – biochemical, microbiological, radiological

Operation record

Hospital course

Plan, follow up, advice on discharge and drug slip

Discharge summary delivery procedure

Discharges are decided at least one day prior and informed to patient and relatives in

advance

The patient-in-charge doctor prepares the discharge summary by filling in details on a

typed standard format available in the department

The discharge summary has patient’s clinical history, findings, diagnosis, investigation

results, treatment given/procedure done, condition at discharge, advice on medication and

other instructions on discharge

Discharge summary also contains the details of follow up visits and whom to contact in

case of emergency

In case a patient dies in the ward a death summary is g iven stating the cause of death

Discharge summaries are prepared by resident doctors and the consultant verifies and signs

before handing over to patient and is kept in the depart mental folder for future reference

A copy of discharge summary and letter about the course of patient in hospital is send to the

referred doctor

A folder is maintained in departmental computer which includes complete detail of patient

including visit summary, discharge summary, operative photographs, clinical photographs,

representative radio logical imaging, operative videos and follow up details

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Services

In-patient services

Surgical gastroenterology Ward (46/47)

Surgical Gastroenterology ward is located in the fourth floor of Super specialty block, with

20 sanctioned general beds, and four individual special pay rooms. Ward is well equipped with the

upgraded infrastructure for patient care needs, run by trained nursing staff who have special interest

in gastro intestinal care and round the clock doctors to extend the best health care support to

patients.

Infrastructure includes adjustable cots with side railings, cardiac tables, separate oxygen

and vacuum pipelines for individual patients, water heater systems, water purification systems, cold

storage systems, non-touch infrared thermometers, separate digital weighing machines including a

200 Kg machine used exclusively for bariatric patients. Procedure room hosts an examination table

with all essential equipments. Adjustable trolleys have made transfer of patients comfortable and

safe. Also equipped with desktop computer, high definition display, printers to facilitate digital data

maintenance and cordless phones to support staff at work. With infusion pumps, pulse oximeters,

automated BP apparatus, the infrastructure is state of the art for perusal of doctors and nursing staff.

Safety mechanisms like fire safety are periodically checked and monitored. Technical and

mechanical support has always been prompt and service expedious.

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Services

Intensive care unit (ICU)

Surgical Gastroenterology intensive care unit shortly called as SGE ICU (146A/SSB18)

is a state of the art surgical care facility. It is situated in the first floor ICU Complex of

Super specialty Block. It is an air conditioned 6 bedded intensive care unit exclusively for

critically ill patients and post-operative patients with gastrointestinal surgical ailments. SGE ICU

provides individualized continuous medical attention. It has the facility of cardiac respiratory

monitors for each bed along with oxygen, air and suction supply. Apart from this it has three

mechanical ventilators (Carefusio n USA, Neumovent Schiller), infusion syringe pumps, aerosol

nebulizers, bair-hugger warmer & thermocare disposable warmer blankets, PCA syringe pump &

disposable ambulatory PCA pumps to manage all the needs of a critically ill patient. It also has 12

lead ECG equipment & defibrillator for cardioversion. A state of art Motorola EPOC cartridge

based portable Arterial Blood Gas (ABG) machine with blue tooth printer helps in

management of critically ill patients. The prosound HITACHI ultrasound machine helps in bed

side imaging. CT and MRI Image viewing through PACS helps for quick decision making and

interventions for critically ill patients.

Fully equipped emergency cart makes it possible to face any kind of medical

emergencies that may arise in the ICU. Appropriate storage of medicines is ensured by a 277 liter

storage capacity refrigerator. To maintain proper anti septic measures, 500ml hand rub is placed

outside entrance of ICU and its made mandatory to use hand rub for all entering inside and a

coat stand to place coats. Besides a 500ml hand rub is placed in all bedsides, segregation of bio-

medical wastes at source, needle burner and sharp container help to fight against hospital

acquired infect ions and ensures personnel safety. Patient’s nutritional needs are calculated by a

full time dietitian. Enteral feeding is promoted, parenteral nutrition support is provided when

needed. SGE ICU is provided with an induct ion cooker and a mixer grinder for customized food

preparation. The SGE team including the faculty rounds twice a day that helps in early

interventions and treatment planning. One senior resident is stationed in ICU round the clock.

There are totally ten staff nurses, two in charge sisters and one nursing orderly in ICU who render

excellent nursing care. Nursing rounds are done three times a day apart from continuous nursing

care.

Many standard operating procedures (SOPs) and checklists including quality rounds

checklist (QRC) are being followed. Learning atmosphere is created among staff nurses by

promoting continuing nursing education by formal presentations weekly and bed side teaching

daily. Handover protocols ensures effective information transfer during duty shifts. HIS (Hospital

information system) connectivity in ICU helps to retrieve real time information, digitalize patient

records and foster patient’s privacy. Twice daily status report of the patient’s condition will be

provided to the relatives. The Notice board outside ICU displays the ongoing events as well as

provides patient family education regarding disease conditions, management, and home care.

Resources are optimized to save the cost without compromising care, efficacy and safety. All the

events in the ICU are audited through weekly morbidity mortality meetings at the departmental

level.

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Services

Surgical gastroenterology operation theatre

Surgical Gastroenterology operating room (OR No. 10) is located in the OT complex in

the first floor inpatient block of super specialty block. It is a dedicated operating room

exclusively for surgical gastroenterology patients. Endoscopic procedures and percutaneous

interventions are performed in OR No 6. Operation room is functioning five days a week. This is a

centrally air conditioned modular OT with laminar flow, HEPA filters and positive air

pressure system. Temperature is maintained at 20± 3°C and humidity between 40 – 60% which

will be constantly monitored in control panel display inside the O.R suite. Two fully equipped

emergency carts and a defibrillator make possible any kind of emergency arising pre operatively

or intra-operatively to be managed effectively. Appropriate storage of medicines, blood products and

hemostatic agents are ensured by a refrigerator. Advanced anesthesia machine incorporates a

ventilator, suction unit and a cardio respiratory monitoring device. Infusion pumps, Blair hugger

patient warmer, blood & fluid warmers (Ranger and EnFlo) prevent hypothermia. HIS and PACS

are available inside OT. Myrian XP liver radiology workstation helps in virtual reconstruction and

effective contemplation of liver resections. Complex hepatopancreatobiliary, gastrointestinal and

advanced laparoscopic procedures are being performed in this department. Basic instruments,

retractors, different types of vascular and special instruments are available for performing simple

to complex cases. Recording systems are used to record the operative procedures. Stryker

modular laparoscopic console and all laparoscopic instruments are available to perform advanced

laparoscopic and bariatric surgeries. New version Harmonic generator, Ultrasonic liver

dissection workstation from Soring, Karl storz choledochoscope, radio frequency ablator and

advanced electro cautery from ALSA makes the OT state of the art. OT store ensures adequate

supply of consumables like staplers and hemostats. Focusing on patient safety and ensuring

quality, use of WHO surgical safety checklists, patient transfer slips, visible white boards

for counts, patient strapping, shifting trolleys with side rails etc. are well in practice. To prevent

infect ion, strict procedures for surgical scrubbing, gowning, gloving, and use of three layered

water resistant surgical gown/drapes are followed. Systems for segregation of bio medical wastes

at source, needle burning and containers for sharp item disposal are in use. Autoclaving, ETO and

Plasma sterilization are ensured as per protocol. Weekly washing, AC vent cleaning and

fumigation processes are being done strictly. Focusing on personnel safety, orientation sessions

on hand hygiene, infect ion control, needle stick and fluid splash injuries and hepatitis B

vaccination are conducted regularly.

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DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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OT-6

OT-6 is utilized by both Medical and Surgical Gastroenterology units. It is fully equipped

with advanced endoscopic and fluoroscopic gadgets. Diagnostic and therapeutic endoscopic

procedures including endoscopic ultrasound and Endoscopic Retrograde Cholangio

Pancreatography (ERCP) are done in a regular basis by Medical Gastroenterologists. Percutaneous

interventions including Percutaneous Transhepatic Biliary Drainage (PTBD) and Percutaneous

Catheter Drainage (PCD) are done under fluoroscopic guidance by Surgical Gastroenterologists.

Surgeries requiring endoscopic assistance including Intraoperative enteroscopy are done there.

Rendevous procedures combining use of endoscopic and percutaneous approach for difficult

biliary strictures, endoscopic ultrasound guided aspiration cytology and drainage, percutaneous

endoscopic gastrostomy and other advanced interventions are also being done. Protective measures

against radiation hazard are ensured.

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DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Endoscopy

Endoscopy suite of surgical gastroenterology department is shared with the

department of medical gastroenterology and is situated at Room No 304 near the surgical

gastroenterology OPD. Endoscopies are routinely performed on Wednesdays and Fridays.

Endoscopy room is equipped with upper GI scope, side viewing and lower GI scope. Both

diagnostic and therapeutic scopies are performed. The therapeutic procedures include

esophageal stricture dilatation, variceal ligat ion, variceal injection, glue inject ion and biopsy.

One nurse, one endoscopy technician and one nursing assistant helps in performing endoscopies.

A recovery room is situated nearby where pat ients are kept for a while after endoscopy.

Endoscopies and therapeutic procedures are mostly performed on a day care basis without

admission. Strict asepsis is followed during the procedure. Prior appointment is given for

endoscopy.

Intervention services

Intervention services provided by the department include percutaneous drainage of

abdominal collections, percutaneous trans-hepatic biliary drainage (PTBD) and trans-hepatic

arterial chemoembolization (TACE). The department has ultrasound machine and image

intensifier. Feasible procedures are done bedside. PTBD is done in collaboration with radio logy

and TACE is done in collaboration with cardio logy. The biliary intervention procedures include

PTBD, internalization, stenting, trans-PTBD biopsy and stricture dilatation. The biliary

intervention procedures are being performed as pre-operative biliary drainage or permanent

palliation. Facility for metallic stenting is also available. Angiographic interventions include

TACE and trans- hepatic arterial chemotherapy (TAC). Macro aggregated albumin (MAA) scan

is done in the department of nuclear medicine before TACE to rule out significant systemic

shunting. Pre-operative portal vein embolization both through ileocolic and trans-hepatic

approaches are being performed. In patients with big tumors, pre-operative therapies help to

reduce the size of tumors so that they can be resected later.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Out-Patient Services

Outpatient clinic

Surgical Gastroenterology OPD (SGE OPD) is situated in the second floor of

superspeciality OPD block room No 305. Initially OPD was started with 2 working days

(Monday and Friday). From 2013 it was increased to thrice weekly (Monday, Wednesday and

Friday). In 2015, it was extended to 6 days a week (Monday to Saturday).

Working hours: Monday to Friday: 9 AM to 1 PM Saturday: 9 AM to 11 AM

The Department faculty and MCh residents takes care of OPD patients after registration

in OPD reception. Separate consultation rooms are allotted for consultants and residents. OPD

dressing room is equipped with instruments for dressings and stoma dressing room is available

to take care of stoma patients. OPD complex also has separate stoma clinic, diet clinic and

MSW clinic on all OPD days to cater needs of every patient. OPD is equipped with audio

visual system in the waiting hall which plays department introductory video and other health

awareness videos in local language for the benefit of patients

Procedure for admission of patient

Our department policy is to admit and evaluate patients visiting OPD if there is any

suspicion of malignancy. This is to avoid waiting period during evaluation on OPD basis.

Patients are admitted in SGE ward which is located in 4th floor of superspeciality IP block.

Patients are given choice of either general ward or special ward. General ward is completely free

and special ward is having minimal charges. Patients are admitted on priority basis with

malignancy patients getting first priority. Significant proportion of patients are transferred from

various specialities too for further expert management. Every effort will be made to borrow

beds from other departments on a temporary basis in case of shortage of beds.

Emergency admissions

Those requiring admission urgently will be admitted depending on the intensity of care

required in the ICU, General Ward or Private Ward as the case requires and availability of beds. In

case of need for emergency surgical intervention, emergency anaesthesia team is informed and

patient shifted to emergency OT in the 3rd floor of casualty block for surgery

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Ostomy services

The Stoma Clinic in the Department of Surgical Gastroenterology was

conceptualised and commenced from June 2013.Two staff nurses were sent for ostomy

training at Tata Memorial Hospital Mumbai in 2013 and 2014 (three months each).

Initially, stoma services were provided thrice a week. From 05.05.2014, these services are

available 5 days a week. Along with OPD services, the ostomy nurses pay daily visit s to all

stoma inpatients in the Department of Surgical Gastroenterology. They also receive direct

references from other Departments in JIPMER like Surgical oncology, Pediatric surgery,

Urology, General surgery, Radiotherapy, Medical oncology, Emergency Department, PMRC,

Neuromedicine, Neurosurgery and Gynecology for stoma care and also care of pressure

sores. The services provided by the Ostomy nurses include pre-operative stoma

counselling, stoma marking, select ion of stoma appliances, application of appliances, stoma

wash, care of bedsore and intestinal fistula management. They also provide advice to patients

with stoma during discharge for stoma care and provide follow up care. The types of stoma

managed by the team includes colostomy, ileostomy, jejunostomy, bowel fistula, duodenostomy,

caecostomy, esophagostomy and urostomy. They also manage stoma related complications like

peristomal skin excoriation and allergic dermatitis. Till date, the team has paid a total of 1613

visits to patients with stoma with a median of 3 visits per patient. 40 percent patients had

more than 5 visits. Since November 2015 Ostomy nurses have been dedicated full time to

ostomy service, provided from 7.30 am -3.30 pm. There is one ostomy nurse posted in

OPD and another ostomy nurse for IP service. On call emergency services are also available.

An Ostomy support group has also been formed recently and is scheduled to meet once in 3

months.

Their main area of services involves Superspeciality block (35%),Old block

(56%);others being EMSD,RCC,WCH,PMRC (1-3% each).The stoma in-patients are

provided with free stoma appliances. The process of provision of free appliances to OPD

patients is in the pipeline. Various activities like ostomy and wound care training

programmes, stoma product demonstration programmes and two stoma day celebrations

have been conducted by ostomy nurses in JIPME R. The team has been involved in mentoring

Ostomy clinic at Stanley Medical College, Chennai.

In future, augmentation of education material, extending advisory and training

services outside JIPMER, care of all bedsores in JIPMER, organizing monthly in service training

for other nurses and initiation of ostomy training course to make JIPMER a training centre

for ostomy care is planned.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Nutritionist services

A full time Dietician is available in the SGE Department in all working days. Dietician

rounds is done once in a day regularly in SGE ICU and Ward. Separate diet order sheets are

used in ICU and Ward to communicate patients nutritional needs to the staffs.

Assessment of patient’s nutritional status is done on the first day of admission and appropriate

intervention is carried out based on the nutritional status. Special attention is given to all

preoperative and postoperative patient’s nutritional needs by offering nutritional support

counseling to the patients and their attenders. Diet chart are prepared according to patients

individual nutritional needs and regular monitoring is carried out to check the nutritional

intake of patient. Special blenderized feeds are prepared for achieving the nutritional needs of

enteral feeding patients.

Dietician is available in SGE OPD during the OPD days for consultation and

counseling of new cases and follow up cases.

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JIPMER, PUDUCHERRY

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Medical social services

Medical Social worker acts as an intermediate link between the medical team and the

patients in order to make the patient at ease and well informed. The Patients, care givers and

family members are assisted to cope with problems resultant to illness and treatment through

comprehensive psychosocial support and care. The Patients are assessed for emotional

wellbeing, mental health, social support, financial problems for focused intervention. The

services include supportive and adjustment counselling, pre and post-operative

counselling, health education and clarifications on disease conditions and treatment procedures,

counseling on treatment adherence, individual, couple and family counselling, group therapy,

palliative support, crisis intervention, financial assistance, guidance on availing community

resources and referrals. The patients are regularly consulted in the OPD, the in-patients in the

ward and intensive care units are provided bedside counselling and support. Assessments and

interventions are done systematically and are being documented. Frequent surveys are

conducted to assess the patients’ satisfaction to the care delivery system.

Medical social worker ensures that the informed consent is being provided both to the

patient and the relatives in a structured way using comprehensive educational materials.

Diagnosis, the need of the operation, its antecedent advantages, possible complications, the

post-operative recovery and follow up plans are discussed in detail.

The availability of various government schemes and insurance schemes to get

treatment are appraised to the patient. They were motivated and guided to the insurance cell for

quick approval for support.

Medical social service extends to staff wellness as well. Various surveys are

conducted to assess the staff satisfaction and the departmental administration is appraised

about possible interventions.

The Medical Social Worker can be consulted in all working days in the OPD.

Research projects aimed at perception and interventional counseling are also conducted.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No. 10

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Quality and safety

Maintaining Quality and safety in patient care is one of the foremost priorities of the

department. This is continuously maintained through various mechanisms. JIPMER quality

council (JQC) guidelines in the JIPMER manual on patient safety are followed in all patient

care areas. All staffs in the department are motivated in patient safety and are given regular

training by quality managers of various domains. Standard operating procedures (SOPs),

checklists and guidelines are developed, followed and audited. WHO surgical safety checklist,

patient transfer SOP, quality rounds checklist (QRC), medication prescription-administration

chart etc. are followed.

Patient identification accuracy is maintained before all interventions. Hospital acquired

infect ions, medication safety, operation room safety, workforce safety, blood transfusion safety

etc. are given prime importance. The department has an event reporting system in which

all adverse events are recorded and reported. Root cause analysis (RCA) are done for all

significant adverse events.

The department of surgical gastroenterology was the first department to establish a

comprehensive departmental clinical auditing system in JIPMER in 2011. Electronic patient

record and data keeping are given care and precision. All the discharges are presented in

weekly morbidity-mortality meetings (MNMs). Clinical auditing is done at doctors and nurses

levels. Service area wise auditing system (OPD, ward, ICU, OT) was initiated in the year 2015.

Annual MNMs and audit meetings help us in identifying the system performance and

areas of improvement. The department supports other departments to establish good

clinical auditing systems.

Two research studies in the area of patient safety are ongoing in the department.

Surgical gastroenterology ICU is acting as the nodal station for needle stick injury reporting and

body fluid exposure management for staff in the superspeciality block. Monthly orientation

programme on various aspects of patient safety is a regular affair. Best efforts are put in place to

maintain quality and safety of the highest order matching international standards.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Services

Telemedicine and telehealth

JIPMER has been designated as Regional Resource Centre for telemedicine activities in

South India with an infrastructure of high speed (1Gbps) internet connectivity and

satellite connectivity with various national and international networks including the

Telemedicine Development Center of Asia (TEMDEC), Asia Pacific Advanced Network

(APAN) and Trans-Eurasia Information Network (TEIN) which enable JIPMER, a tertiary

care Institute of National Importance, to share knowledge with different countries. Our

department participates in telemedicine programmes and webinars at frequent intervals w ith

well renowned national and international surgical gastroenterology centers.

Patient information materials and videos

Information materials are made available in departmental website for various

diseases like Anterior Resection, distal pancreatectomy, esophagectomy etc. for the benefit of

patient which includes details of various diseases, risk factors, preventive measures,

symptomatology, diagnostic measures and management options in a simple language for better

understanding. Patient information videos are being prepared for 20 common gastrointestinal

disorders in their local language.

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DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Policies for assessment of patient

When patients are admitted, they are seen by a nurse and housekeeping instructions given

along with any stat orders if any

The doctor in charge of the bed or the duty doctor will see the patient as early as possible

The doctor will do an initial work up, write the care plan and the medications and send

necessary investigations required

Reports of blood investigations are available online through HIS from ward and

radio logical investigations through PACS

Dangerously abnormal results are intimated by concerned lab personal to treating resident

or consultant directly through telephone.

Patients are shown to respective consultants and plan discussed and decided in the round

Drug prescript ions are written in drug chart and it is changed daily or as and when

required.

Standard operating procedures prepared by the department according to Evidence based

surgery is used for managing the patients.

All the patient information’s are kept confidential and online access is restricted by

password

Patients are seen at least twice a day by the resident doctors. During each visit the clinical

status is recorded in the progress notes along with date, time and signature

When the concerned doctor is not available, the responsibility is handed over to another

doctor of the same unit or the duty doctor

Dietician will see, evaluate and advice diet for the admitted patient

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No. 11

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Clinical programmes

Hepato-pancreato-biliary (HPB) surgery

The department has established itself as a center of excellence for HPB surgery in the

region of Puducherry, Tamilnadu, Kerala, Andhra Pradesh and Telangana. Benign and malignant

disorders of HPB system are being managed according to the standard operating procedure

protocol of the department. Advanced HPB surgeries performed in the department include

Hepatectomies (Major & minor) for Hemangioma of liver, Hepatocellular carcinoma, Intra hepatic

& hilar cholangiocarcinoma, Colorectal & neuroendocrine liver metastases, intra hepatic stones,

radical cholecystectomy for carcinoma gallbladder, choledochal cyst excision, common bile duct

exploration, Whipples pancreatoduodenectomy for periampullary carcinomas, head coring &

duodenum preserving pancreatic head resection, distal pancreatectomy for chronic pancreatitis,

cystoenterostomy for pseudocyst of pancreas and procedures for cystic neoplasm of pancreas,

necrosectomy for acute necrotizing pancreatitis. The energy devices required for advanced HPB

surgeries like Harmonic scalpel, CUSA, vessel sealer are available in the state of art operation

theatre of the department.

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DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Clinical programmes

Advanced laparoscopic surgery

Advanced minimally invasive surgery has been one of the thrust areas of the

department. Majority of the benign and malignant disease affecting the gastrointestinal

tract, liver, pancreas and biliary tract were managed laparoscopically/thoracoscopically in the

department. Minimally invasive surgery is the procedure of choice and no longer an

option for the majority of the gastrointestinal disorders treated in the unit. The department

is establishing itself as a center of excellence for minimally invasive surgery in the region of

Puducherry, Tamilnadu, Kerala, Andhra Pradesh and Telangana.

The department faculty received minimally invasive surgery training from best centers in

India and abroad. The operation theater is equipped with state of art full high definition

Stryker laparoscopic camera system with the video monitor. High-end energy devices like

laparoscopic harmonic ace plus probe, Enseal devices and laparoscopic CUSA are available to

perform complex laparoscopic and thoracoscopic procedures. In addition, the department is

equipped with advanced laparoscopic instruments like laparoscopic vascular clamps, flexible

trocars, gel port system, autosuture device etc. All types of laparoscopic staplers and cartridges are

available in the department.

Advanced minimally invasive procedures performed in this department include

thoracoscopic esophagectomy, thoracoscopic assisted esophagogastrectomy, laparoscopic total

gastrectomy, laparoscopic sleeve gastrectomy, laparoscopic cardio myotomy, laparoscopic

fundoplicat ion, laparoscopic retrosternal gastric bypass, laparoscopic right hemicolectomy,

laparoscopic anterior resection, laparoscopic low anterior resection, laparoscopic

intersphincteric resection, laparoscopic abdominoperineal resection, laparoscopic

splenectomy, laparoscopic distal pancreato-splenectomy. JIPMER is one of the few centers in

India to perform the most complex laparoscopic procedures like laparoscopic

pancreatoduodenectomy and laparoscopic liver resection.

Research projects are underway to study the feasibility and significance of thoraco -

laparoscopic radical surgery in esophageal cancer and laparoscopic preconditioning procedures

which can minimize the complications after this radical surgery. The department had taken a

lead in minimally invasive training by conducting multiple minimally invasive surgery skills

courses for trainee surgeons, practicing surgeons and staff nurses. Basic and advanced

laparoscopic simulators including those with haptic feedback and robotic simulators were used

for these minimally invasive surgical skills courses.

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DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Clinical programmes

Obesity and metabolic surgery

Obesity is increasing in an alarming proportion and it is no longer a cosmetic concern

and is a risk factor for diabetes, hypertension, coronary heart disease and multiple

other non- communicable diseases. Although the surgery for obesity was originally developed

as a weight reduction therapy, it has been reported to improve type 2 diabetes and to reduce

rates of cardiovascular diseases and death. Hence, the term metabolic surgery is preferred over

bariatric surgery to highlight the metabolic benefits of these surgical procedures. JIPMER is

one of the few major Government institutes in the country to have an established metabolic

surgery programme.

The successful metabolic surgery program requires a comprehensive care that includes

adequate pre-operative education, nutrition and lifestyle counselling, challenging perioperative

care, as well as post-surgical support. A multidisciplinary expert team of Surgeons,

Endocrinologists, Pulmonologists, Cardiologist, Psychiatrist, Anesthesiologists and Nutritionists

ensures comprehensive care for these patients. Obesity and metabolic surgery programme was

inaugurated on 24/03/2015 by Dr S C Parija, Director, JIPMER. The department faculty trained

in advanced laparoscopic gastrointestinal surgery performs these complex operations.

The Surgical Gastroenterology operation theater is equipped with the battery

powered operation table with adequate width, weight capacity, leg separation and lithotomy

facilities. In addition a full high definition Stryker laparoscopic camera system with the video

monitor, long trocars and cannula, long laparoscopic instruments, vessel sealing systems and

endoscopic staplers are available to perform these operations. In the postoperative period these

patients are managed in a dedicated intensive care unit with real time monitoring of blood

pressure, oxygen saturation and electrocardiogram. In addition ventilators and continuous positive

airway pressure mask for the management of obstructive sleep apnea.

Currently, laparoscopic sleeve gastrectomy and laparoscopic Roux En Y gastric

bypass are the preferred metabolic surgical procedure offered to these patients. Patients are

advised to bear the cost of the consumables used in operation which is 20% of the expenses in

corporate hospitals.

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

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Classification of diseases and conditions

Organs

• Esophagus

• Stomach

• Duodenum

• Small bowel

• Colon and rectum

• Liver

• Gall bladder and biliary tract

• Pancreas

• Spleen

• Abdo minal wall

Diseases and conditions

• Esophagus- cancer, achalasia, hiatus hernia, corrosive injuries, stricture, perforation,

foreign body

• Stomach- cancer, stromal tumors, peptic ulcer, bleeding lesion , gastric outlet obstruction,

obesity

• Duodenum- cancer, ulcer, obstruction, malrotation, duplicat ion

• Small bowel- cancer, lympho ma, tuberculosis, perforation, obstruction, bleeding, fistula, and

acute appendicit is

• Colon and rectum- cancer, lymphoma, obstruction, vo lvulus, bleeding lesions, stoma

• Liver- cancer, cirrhosis, hydat id cyst, benign liver tumors, stone disease, abscess, portal

hypertension

• Gall bladder and biliary tract- cancer, benign tumors, stone disease, cholangitis

• Pancreas- cancer, benign tumors, acute pancreatitis, chronic pancreatitis , cyst

• Spleen- tumors, spleen in hematological condit ions

• Abdo minal wall and hernias- Incisio nal hernia, inguinal hernia.

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JIPMER, PUDUCHERRY

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Classification of diseases and conditions

Surgical procedures performed

• Esophagus- Transthoracic esophagectomy, Trans hiatal esophagectomy,

thoracoscopic esophagectomy, esophageal bypass, esophageal replacement,

laparoscopic esophageal bypass, laparoscopic cardio myotomy, laparoscopic

fundoplicat ion

• Stomach- Radical gastrectomy, simple gastrectomy, laparoscopic gastrectomy,

laparoscopic gastric bypass, laparoscopic vagotomy

• Small intestine - Duodenal resect ions, laparoscopic perforation closure, laparoscopic

segmental resections, laparoscopic feeding jejunostomy, laparoscopic adhesio lysis.

• Colon and rectum- Laparoscopic right hemicol e c tomy, laparoscopic left hemicolectomy,

laparoscopic anterior resection, laparoscopic abdominoperineal resect ion, total colectomy,

ileal pouch anal anastomosis, sphincter preserving surgeries, stoma, stoma closure,

laparoscopic appendicetomy.

• Liver- Right hepatectomy, left hepatectomy, trisectionectomy, segmental liver

resections, laparoscopic left lateral sectionectomy, portal vein embolization, Trans

arterial Chemo Embolization (TACE), percutaneous transhepatic biliary drainage

(PTBD), splenorenal shunts, mesocaval shunts, devascularisat ion.

• Gall bladder and biliary tract- Laparoscopic cholecystectomy, laparoscopic CBD explorat ion,

radical cho lecystectomy, extended radical cho lecystectomy, hepatopancreatoduodenectomy

• Pancreas- pancreatoduodenectomy, Frey’s procedure, Beger’s procedure, Duodenum

preserving pancreatic head resect ions, lateral pancreatojejunostomy, laparoscopic distal

pancreatectomy, spleen preserving pancreatectomy, pancreatic pseudocyst drainage,

necrosectomy

• Spleen- Laparoscopic splenectomy, partial splenectomy

• Abdo minal wall- laparoscopic incisio nal hernia repair, laparoscopic inguinal hernia repair

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No. 13

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Academic schedule and Review meetings of the Department

Our department has regular scheduled programme for academic and monthly audit

meetings. This helps in improving scientific knowledge of the staffs and to review the

shortcomings, thereby overcoming them subsequently. The adverse events are promptly reported

and a record of such incidences are maintained.

There are various academic activities involving faculties and senior residents held in the

department. Journal club involves critical analysis of a published research paper, appraising its

limitations and finding its applicability. Seminars on selected topics, current evidence in

advances and future perspective are held in regular basis. Case presentations in a structured

format helps senior resident trainees well versed for their practical exams. Exclusive monthly

lecture by faculties provides in depth theoretical and practical concepts in particular topics.

Review of inpatients individually, their morbidities and follow up are recorded and reviewed in

monthly basis. We also have discussion of cases which have multidepartmental role in

management by conducting interdepartmental meets.

Monthly Academic schedule

Academic activity Numbers

Journal Club 4

Case presentations 4

Case capsule 3

Seminars 2

Individual patient audit meet 1

Mortality audit meet 1

Faculty lecture 1

Gastro Pathology meet 1

Gastro Radio logy meet 1

The department monitors academic and research activities periodically, to assess progress

of senior residents. Review meetings with associated health care professionals regularly helps to

implement day to day practical shortcomings, thereby providing better patient care.

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JIPMER, PUDUCHERRY

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Academic schedule and Review meetings of the Department

Review meetings schedule

In addition, we have regular teaching schedules at various levels including Continuous

Medical Education (CME), Continuous Nursing Education (CNE), workshops in basic

ventilator management, infect ion control, hospital waste management, postoperative ICU care and

transfusion guidelines, which helps our staffs to stay in line with current practices according

to international guidelines.

Review meeting Schedule

Annual department meeting Once in a year

Faculty meeting Once in three months

Resident progress meeting Once in six months

Resident committee meeting Once in six months

Sister in charges meeting (Dr Biju) 1st

Friday of month

ICU meeting (Dr Sandip) 1st Tuesday of month

Ward meeting (Dr Kalayarasan) 2nd

Tuesday of month

OPD and stoma meeting 3rd

Tuesday of month

OT meeting (Dr Biju) 3rd

Friday of month

Office meeting 4th

Tuesday of month

Department quality cell

(Dr Biju)

Once in three months

Nursing research cell

(Dr Biju)

Once in three months

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JIPMER, PUDUCHERRY

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Department quality cell

Quality cell was formed in the year 2015 with the aim of improving the quality of care provided to

the patients. Functions of quality cell are

1. Reporting of adverse events in department

2. Root cause analysis & auditing of such events

3. Implementation of corrective measures

4. Implement Jipmer Quality Council protocols in department

Department quality cell meets once in three months. Members of quality cell are:

1. Dr Biju Pottakkat – Additional Professor & Head

2. Mrs. Thilagavathi. T – ANS Nursing incharge

3. Ms. Vyshnavi. M – Staff nurse (Ward)

4. Mr. Dhinakaran. S – Staff nurse (OT)

5. Ms. Pavithra. M – Staff nurse (ICU)

Nursing research cell

Research forms a major part of our nursing faculties in the department. In order to further

promote and motivate research among nursing faculties, nursing research cell was formed in the year

2014. This body meets once in three months. Research topics are selected and ongoing which

ultimately helps in providing better patient care. Members of nursing research cell are

1. Dr Biju Pottakkat – Additional Professor & Head

2. Mrs. Thilagavathi. T – ANS nursing incharge

3. Ms. Saranya. S – Staff nurse (ICU)

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JIPMER, PUDUCHERRY

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Co-ordination of extra departmental training and orientation programmes

Following will act as organizing secretaries

1. Basic laparoscopic skills courses for doctors Dr Sandip

2. Advanced abdominal surgery skills courses Dr Kalayarasan

3. Basic laparoscopic skills courses for nurses Sr. Uma

4. All intensive care and infection related programmes Sr. Indirani

5. All quality and care related programmes Sr. Kiruthiga

6. All stoma and wound care related programmes Sr Priya Grace

7. All nutrition orientation programmes Ms Dhilshat

8. All staff and patient communication orientation programmes Ms Hena

HOD will act as organizing chairman of all programmes. ANS will act as convener of all

programmes except 1 and 2. All organizing teams are requested to organize a minimum of four

programmes in a year aimed for JIPMER staff and outside delegates.

Simulation laboratory

Simulation laboratory in the department is one of the best in the country in surgical

simulation. The skills lab room is located in OPD hall complex near Room No 305, second floor,

OPD block, superspeciality complex. Basic laparoscopy simulation room and advanced surgical

simulation room are located in two different halls.

Basic laparoscopy simulation centre:

Equipped with three box simulators (Ethicon endo-surgery) with hand instruments for

training.

Advanced laparoscopy simulation centre: Equipped with following:

• Two laparoscopic haptic simulators- Lap mentor express

• One Virtual reality laparoscopic simulator- CAE

• RoSS robotic surgery simulator – first of its kind in India

• Ultrasound and echocardiography simulator- CAE

• Myrian liver radio logy simulation work station

• Ostomy trainer

The simulation centre in the department is pioneer in the country in initiating curriculum based

simulation surgery programme.

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DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No. 14

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Fire safety plan- Superspeciality Block (SSB) Fourth Floor

1. Resources:

i. Human resource: All staff working in the fourth floor of SSB.

ii. Firefighting resources in the fourth floor of SSB:

a. Active:

i. Fire alarms -smoke detectors as well as manually activated alarms.

ii. Fire extinguishers.

iii. Fire sprinklers.

iv. Fire hydrants and hose reel.

b. Passive:

i. Fire exits are provided on either side in each floor.

ii. Emergency power back up.

2. Common meeting place at the time of evacuation:

Open ground located near the garage of the EMS department.

3. Floor plan of the Wards in the Fourth Floor of SSB (See diagram)

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• The Ward in the fourth Floor of SSB has a main corridor leading to exit corridors on either

end – the northern end corridor has the emergency (fire) exit on the eastern end.There is also

one elevator (lift) next to the emergency exit. The southern end of the main corridor leads to

the main landing elevators (lift) and staircase. There are four cubicles, two nursing stations,

pantries, four bathrooms, toilets, and special wards on the eastern side of the corridor.

• There are six cubicles, three nursing stations, pantries, six bathrooms, toilets and

procedure rooms on the western side.







• The main entrance to the ward is fro m its southern end where the lift s and staircase landing

are located.

• There is an Emergency (Fire) Exit on the eastern side of the north end of the main corridor.

• There are signs indicating direct ion of the nearest exit along the corridors.

• The emergency exits should be opened at all times. DO NOT LOCK. If locked keys should

be easily available.

4. Fire Extinguisher location

• Available all along the corridor of the fourth floor and in the pantries.

5. Action to be taken for containing and extinguishing fire

The senior most nursing staff on duty in the ward opposite the one where fire event

occurred and on hearing the alarm ‘Code red’ must take the measures for containing and

extinguishing fire and act as the leader of the ‘fire control team’.

She/he will:

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• Remove or direct the nearest available staff member(s)to remove patients and other persons,

valuable records and equipment to the extent possible as well as any inflammable articles in

the vicinity of the fire.

• Close or direct closing of all windows and doors after essential items and people have been

removed

• Call the nearest person to retrieve the nearest fire extinguisher. Operate or direct the

operation of the fire extinguisher using the ‘PASS’ technique to extinguish the fire.

• Fire extinguisher is best carried by two persons.

• Instruct the switching off of the electrical mains supply of that section as early as

possible after informing the ‘fire marshal’ and the ‘ward medical care team’ leader.

• Instruct the switching off of the medical oxygen supply of that section as early as

possible after making sure from the ‘fire marshal’ and the ‘ward medical care team’ leader

that patients needing oxygen support have been shifted to oxygen cylinders.

• Not leave the fire unattended.

• If fire occurs in one of the pantries, treatment/ procedure rooms, store rooms, linen rooms,

lab, special wards or doctors’ / nurses’ counter or duty rooms, then the door of that room

must be closed if the fire cannot be contained after confirming that all people, valuable

records and equipment and inflammable articles to the extent possible have been

removed. There is no door in the ward, hence the question of closing doors do not arise.

• If patient is on fire

Follow Stop, Drop and Roll.

Wrap the person in a blanket before rolling.

• She / he will keep the ‘fire marshal’ informed time to time regarding the gravity of fire and

ask for fire additional fire controlling resources including material and manpower.

• She will also inform the ‘fire marshal’ regarding the need to order evacuation in the event that

fire is not getting contained.

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Evacuation procedure

• The instruction for evacuation will be given by the ‘fire marshal’ after receiving

communication from the ‘fire control team’ that fire is not getting controlled and she / he

will assign such staff as are available for the purpose to the evacuation team.

• A scout(s) should first check safety of evacuation route(s) and report back the safe route

available Prepare and evacuate the building by way o f the nearest emergency exit. Walk as

fast as possible but do NOT run. Do NOT use elevators.

• The elevators (lift s) should not be used for evacuation.

• Before exiting through any closed door, check for heat and the presence of fire behind the

door by feeling the door with the back of your hand. If the door feels very warm or hot to

the touch, advise everyone to proceed to another exit.

• Once instructions for evacuation are given the senior most nursing staff of the ward

adjacent to the one on fire must coordinate evacuation.

• He / she will act as the leader of the ‘evacuation team’ and keep the ‘fire marshal’ informed.

• First all visitors and attendants of patients not in need of assistance are asked to leave the

ward immediately.

• Next patients who are stable and ambulatory are asked to walk down the corridor to nearest

exit leading away from the cubicle on fire i.e. the main exit, the fire exit, and from there walk

down the stairs and out of the building and assemble at the ‘common meeting point’ located

near the garage of the EMS department.

• Thereafter non-ambulatory i.e. wheel chair patients and bed bound patients (in that order)

will be physically lifted and evacuated through staircases to the third floor and thereafter,

if possible, will be wheeled out through the corridor connecting to the EMS. Use trolley /

slings made of bed sheet /blanket for carrying the patients or the patients must be physical

carried out. For this purpose at least two persons are needed to carry one patient.

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• All hospital staff will assist the different teams and will leave last after ensuring that all

patients have been evacuated on the instructions of the ‘fire marshal’.

• The ‘evacuation team’ leader will assign a nursing staff for coordinating with the help of

hospital security the assembly of patients, other staff and the ‘common meeting point’. Only

patients and staff shall assemble at the ‘common meeting point’. Visitors must be asked to

leave.

• In the event you are unable to exit the building:

Remain calm; do not panic In a smoky room or corridor remain low; crawl if necessary.

Place a cloth, wet if possible, over your mouth to serve as a filter

If trapped in a room signal for help from a window. Use a towel, clothing, sign etc.

• Do not block any driveways and approach to casualty, as Fire Department personnel will

need access to these areas.

• The cessation of an alarm/departure of the fire department is not an "all clear" to re- enter

the building as corrective measures may still be in progress.

• Stay clear of the building until your designated Fire Safety Officer has advised you to re-

enter the building/area.

• In the event of an evacuation order, the priority is to evacuate patients. Visitors must be asked

to leave even before the evacuation order. However, once all patients are evacuated, do assist

visitors in need. Visitors may not be aware of exits/alternative exits and the procedures that

should be taken during alarm situations. Employees should calmly inform visitors of the

proper actions to be taken and assist them with the evacuation.

• At the end of evacuation a roll call must be performed by the ‘fire marshal’ to make sure that

all patients and staff having been evacuated. In case someone is left behind, the fire service

teams that would have arrived by then must be informed to take steps for their search and

rescue

STANDARD OPERATING

PROCEDURES (SOPs) FOR

DISEASES

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Standard Operating Procedure for Achalasia cardia

Achalasia cardia

Evaluation with Barium swallow/ UGI endoscopy

Low surgical risk High surgical

risks

Laparoscopic Myotomy +Fundoplication Medical Management

Failure

Pneumatic dilation/

Esophagectomy

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DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No. 15

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Standard Operating Procedure for Acute Pancreatitis

Acute Pancreatitis

General: Pain relief; Fluid

resuscitation; Nutrition

(Enteral preferred); Antibiotics

(Controversial)

Gall stone pancreatitis

Mild Severe with cholestasis

Conservative ERCP +Stone

extraction

Laparoscopic cholecystectomy

USG/Serum Amylase/CECT

Local Complications

Peripancreatic fluid collection Pancreatic Necrosis

Non Gallstone Pancreatitis

Delayed

Intervention (>4

weeks)

Step-Down

approach

Infected necrosis

Step-Up approach

Percutaneous /

Endoscopic/Laparoscopic

Drainage with necrosectomy

Open Surgical Drainage with

Necrosectomy

Open necrosectomy with:

1)Closed packing 2)Open packing 3)Continuous closed postoperative

lavage 4)Programmed open necrosectomy

Conservative management

Percutaneous Radiological Drainage of residual collections

If no improvement

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Standard Operating Procedure for Benign Biliary Stricture (BBS)

Benign Biliary Stricture (BBS)

Complete Blood Count, Liver Function Tests, Kidney Function

Tests, Ultrasound abdomen(USG) Magnetic Resonance

Pancreatography (MRCP), Contrast Enhanced Computed

Tomography(CECT) in cases of suspected atrophy hypertrophy

complex and malignancy

Clinical Features: Jaundice, Recurrent cholangitis,

Portal Hypertension

Cirrhosis

Absent Present

Early Late

Types I,II,IIIA

Roux- En Y Hepaticojejunostomy with Hepp-

Couinaud approach

Present Absent

Types IIIB, IV& V

Atrophy- Hypertrophy Complex

Drain all atrophic ducts

during surgery

Modified Bismuth Classification of BBS

Liver resection if stricture

extends into subsegmental ducts

Liver Transplantation

Preop biliary

stenting

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Standard Operating Procedure for Benign Gastric Outlet Obstruction

No improvement

After conservative

Treatment

Benign Gastric Outlet Obstruction (GOO)

Stomach decompression and wash

Upper GI Endoscopy and antral biopsy

Laparoscopic/open Truncal

vagotomy and Gastrojejunostomy

Malnourished

/Nutritionally

depleted

Parenteral

nutrition

Anti H pylori

treatment H. pylori

Endoscopic balloon

dilation

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JIPMER, PUDUCHERRY

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Standard Operating Procedure for Carcinoma colon

Carcinoma Colon

obstructed Non obstructed

Contrast enhanced CT abdomen & pelvis;

Carcinoembryonic antigen (CEA), Complete blood

count, Liver & kidney function tests, Colonoscopy

Metastatic Non metastatic

Surgery

Adjuvant

chemotherapy

Resectable

metastasis

Unresectable

Palliative

chemotherapy Staged resection/

combined resection

Adjuvant chemotherapy

Emergency surgery

Resectable (metastatic/

non metastatic)

Unresectable (metastatic/

non metastatic)

Resection adjuvant

chemotherapy

Stoma/ bypass

Palliative chemotherapy

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JIPMER, PUDUCHERRY

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Standard Operating Procedure for Carcinoma Esophagus

Evaluation

Fit patient Unfit patient

Reassessment with CECT scan

C T 1-3/ N 0-1, MO T4,N2-3,M1

Esophageal cancer

Severe dysphagia (grade III- VI)

Most common presentation - Dysphagia

Esophagectomy

UGI endoscopy and biopsy, USG abdomen and CECT neck thorax and abdomen

Carcinoma middle and

lower third esophagus and

within 5 cms of GE junction

Carcinoma upper third

(Within 4 cms of

cricopharynx)

Definitive chemo radiation

Feeding jejunostomy

Neoadjuvant chemoradiation

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Standard Operating Procedure for Carcinoma Rectum

Obstructed Non- obstructed

Sigmoid colostomy

Contrast enhanced CT

abdomen & MRI pelvis,

CXR, Carcinoembryonic

antigen

CECT abdomen & MRI

pelvis, CXR, CEA

Metastatic

Carcinoma Rectum

Neoadjuvant

chemoradiotherapy

Surgery

Early cancer/ lymph node

negative on imaging

Lymph nodes +/ locally

advanced

Neoadjuvant

chemoradiotherapy Surgery

Surgery

Unresectable Resectable

Neoadjuvant

chemotherapy Palliative

chemotherapy

Surgery for primary & metastasis: combined or staged

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Standard Operating Procedure for Carcinoma Stomach

Site

Carcinoma Stomach

No metastasis

Upper GI endoscopy/ CECT abdomen and pelvis

Metastasis

Asymptomatic

Symptomatic-

Bleeding/obstruction

Palliative CT Palliative

Resection/bypass

GE junction and the Cardia

Antrum and pylorus:

Body and fundus

Total Gastrectomy Distal Gastrectomy Proximal Gastrectomy with partial

esophagectomy

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Standard Operating Procedure for CBD Stones

CBDE: Common Bile Duct Exploration; ERC:Endoscopic retrograde cholangiography; ES:Endoscopic

Sphincterotomy; CHD: Common Hepatic Duct; IOC: Intraoperative cholangiography; LUS: Laparoscopic

Ultrasound

Choledocholithiasis +Cholelithiasis

Jaundice,cholangitis

ERC/ES

Laparoscopic

cholecystectomy

Follow up

Laparoscopic

cholecystectomy +IOC/LUS

Transcystic CBDE

Multiple(>8) or

large (>1cm)stones;

stones in CHD

Evaluation by USG/MRCP

Laparoscopic

choledochotomy and CBDE

Failure/Retained stones

Postoperative ERC/ES Open CBDE

Debililated or elderly

patient

Open Surgery

Retained

stones

Remove via T-

Tube

Choledochoduodenostomy

CBDE/T Tube Multiple

stones/Dilated

CBD/impacted

ampullary

stones/ampullary

stenosis

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JIPMER, PUDUCHERRY

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Standard Operating Procedure for Chronic Pancreatitis

Established Chronic Pancreatitis

Trail of conservative therapy, analgesics, alcohol

avoidance & enzyme replacement therapy

Persistent symptoms Additional symptoms / Complications

Differentiate duct morphology by

USG abdomen or CECT abdomen

Small duct disease Large duct disease

- More aggressive pain

management

- Izbicki procedure

- Duct drainage procedure

mostly Frey’s procedure

Only tail involved

- Distal pancreatectomy

+/- splenectomy

Cystogastrostomy /

cystojejunostomy

usually with added

duct drainage

Symptomatic

pseudocyst Bile duct stricture

– LFT, MRCP

Roux-en-Y

Hepaticojejunostomy

with Frey’s procedure

Pancreatic head mass –

Pancreatic protocol CT

Malignancy / suspicious of

malignancy / head

dominant disease -

Pancreatoduodenectomy

Portal

hypertension

Endoscopic duct

drainage preferable

Pancreatic ascites

and pleural effusion

Bowel rest, parenteral nutrition

and octreotide

Pseudoaneurysm –

CT angiogram

Massive GI bleed -

angioembolization

followed by Surgery

later

Persistent pain

even after Surgery

Pain management, celiac

plexus block

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Standard Operating Procedure for Corrosive Injury Esophagus

Corrosive Injury Esophagus

Early admission (48-72hrs) Delayed admission (72hrs- 3 weeks)

Late admission (> 3 weeks)

Early Endoscopy

Mild lesions Severe lesions

Discharge and

follow up

Endoscopy

and dilation

Successful

No endoscopy-

FJ- if severe

dysphagia

Feeding

jejunostomy

Endoscopy +/-

dilation every

3 weeks

Endoscopy +/-

dilation every

3 weeks

Unsuccessful

Endoscopy

Follow up

Esophageal

bypass

Feeding

jejunostomy

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Standard Operating Procedure for Crohns disease

Crohn’s disease

Mild to moderate Moderate to severe Complications:

obstruction, abscess,

perforation

Surgery

Systemic steroids +/_

azathioprine, 6-

mercaptopurine (6MP)

Medical management [e.g.

Budesonide/ 5-aminosaliclic acid

(5-ASA) and its derivatives]

Remission No remission

Maintenance 5-

ASA/

observation Relapse

Remission

No remission

Maintenance

azathioprine, 6-MP,

methotrexate, 5-ASA

Anti TNF alpha +/_

Azathioprine/ 6-MP

Relapse

Maintain on Anti TNF

alpha, azathioprine/ 6-

MP

Remission

Relapse Newer biological agents/ surgery

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Standard Operating Procedure for Esophageal Perforation

Signs and symptoms of esophageal perforation

Drainage

Broad spectrum antibiotics and parenteral nutrition

Exclusion and diversion

Contained perforation

Cervical Thoracic

Primary repair

Contrast esophagography /chest X ray and CECT

Uncontained perforation

Abdominal

No improvement

<24 hrs

Evaluation of perforation

Malignancy

Controlled fistula

Surgical repair tolerable Surgical repair Intolerable

Resection

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Standard Operating Procedure for GERD

GERD symptoms

Typical GERD symptoms Atypical GERD symptoms

Life style modification

& trail of Proton pump

inhibitors (PPIs) +/-

Prokinetics

Symptoms resolve

Symptoms persist

Continue life style

modification and taper

PPIs

If symptoms recur - EGD,

Barium swallow +/- Reflux

Scintigraphy study

Maintenance therapy

with PPIs

Esophagogastroduodenoscopy (EGD), Barium

swallow +/- Reflux Scintigraphy study

Associated with

dysphagia /chest

pain

Manometry + / -

esophageal motility

scintigraphy studies

Associated motility

disorders, then treat

accordingly

No esophagitis

or reflux

24 Hr – pH

monitoring

GERD present No GERD

Seek alternate

diagnosis

GERD complications

like Barrett’s

esophagus, Peptic

stricture

Antireflux surgery + / -

Hiatus hernia repair

Option of antireflux surgery

considered even if medical

management is successful

(quality of life considerations,

lifelong medication, expense

of medications etc.)

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Standard Operating Procedure for GIST

GIST

Primary GIST,

Unresectable

Primary GIST,

Metastatic

Primary GIST,

Resectable

Recurrent GIST

Biopsy

Low risk of

recurrence or

metastases

(<3 cm and

<5 mitoses/ hpf)

Surveillance

Moderate to high

risk of recurrence

or metastases

( >3 cm or >5

mitoses/ hpf)

Imatinib therapy

Surgery

Neoadjuvant

Imatinib therapy

Biopsy

Imatinib therapy

Reimaging

Resectable

Unresectable

Surgery

Imatinib therapy

Imatinib therapy

Imatinib therapy

Responsive

Progressive

Imatinib +/_

Surgery

Sunitinib

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Standard Operating Procedure for Ileo caecal tuberculosis

Obstructed Non- obstructed

X ray abdomen, CXR,

baseline blood

investigations,

resuscitate

Emergency surgery:

Resection anastomosis/

stoma

CXR; Sputum AFB &

culture

Sputum

AFB/culture- +ve

Anti tubercular

treatment

AFB Negative

CECT abdomen

with oral and rectal

contrast

IC thickening

Yes No

Diagnostic

Laparoscopy

& biopsy

Colonoscopy

& biopsy

Negativee

Ileocecal Tuberculosis

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Standard Operating Procedure for Lower GI bleed

Acute lower GI bleed

Assess severity &

Resuscitate

Ruleout low anorectal disorders by

DRE and proctoscopy

Ruleout upper GI bleed by

esophagogastroduodenoscopy

Intermittent or mild to moderate

persistent bleed

Persistent or severe acute bleeding

Colonoscopy

Unstable Stable

Emergency surgery

Source not

identified

Source

identified

Treat lesion

accordingly

Serial clamping or

Intraoperative

enteroscopy and

identification of

lesion – treat

accordingly

Source not identified,

continued bleeding

Tagged RBC scan

Negative Positive

Repeat Colonoscopy,

small bowel studies &

CECT abdomen

Angiography and

embolization or

surgery

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Standard Operating Procedure for Liver Abscess

Suspected liver abscess

Ruptured Un-ruptured

USG abdomen*

U

Free peritoneal rupture

Peritonitis

Start empirical antibiotics against gram

negative and anti amoebic drugs (eg- third

generation cephalosporins + Metronidazole

or ampicillin + aminoglycoside +

Metronidazole)

Per cutaneous drainage

(PCD)/ percutaneous needle

aspiration (PNA) of the

abscess

PCD of collection if not

communicating with abscess

Contained rupture

Surgery

Laparoscopy

laparotomy

Amoebic liver abscess (ALA) likely

Single large abscess

Recent history of diarrhea/

Dysentery (within 6 months)

Stool for ova cyst positive

Nested PCR for E. Histolytica

DNA positive in stools/ saliva/

pus aspirate (if done)

Positive amoebic serology

(poor positive predictive value

in India)

Pyogenic liver abscess (PLA) likely

When secondary biliary causes

identified

Recent biliary intervention

Multiple small abscesses

Negative amoebic serology

Positive culture

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PLA ALA

Early drainage of abscess

PNA if multiple small

abscesses < 5 cm in size

PCD if abscess > 10 cm

For abscess 5- 10 cm both can

be used with more likelihood

of multiple procedures with

PNA

Identify secondary causes-

additional investigations as

indicated*

Continue anti amoebic drugs

No improvement in 3-4

days

Impending rupture (<

1mm overlying liver

parenchyma)

Subcapsular/ contained

rupture

Secondary bacterial

infection suspected

> 10 cm size especially

in left lobe

Culture based antibiotics for 2-

3 weeks

Treat secondary causes if

present

Improvement

Metronidazole for 2 weeks

Luminal amoebicide (eg

diloxanide furoate) for 10 days

Abscess drainage

PNA if small abscess <

5 cm in size

PCD if abscess > 10 cm

For abscess 5- 10 cm

both can be used

Indeterminate

etiology

Inability to positively identify

any of the two types

Continue empirical

antibiotics and anti amoebic

drugs for 2 weeks followed

by luminal amoebicides

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Standard Operating Procedure for Liver space occupying lesion (SOL)

SOP-Liver SOL

Complete Blood Count, Liver Function Tests, Kidney Function Tests, Serum

.alphafetoprotein, Upper Gastrointestinal Endoscopy, Ultrasound abdomen,

Triple phase Computed Tomogram abdomen

Typical features of Hepatocellular

Carcinoma (HCC) on imaging

Follow HCC Protocol

Present Absent

FLR <30% CPT score >8 or S.

Bilirubin > 2 mg% or

FLR< 80%

CPT score < 8

and FLR>

80%

FLR>30%

Resection

Good performance

status

Absent Present

TransarterialChemoem

bolisation supportive therapy

Typical features of Non HCC

tumor on imaging

HCC Protocol

< 5 cm

Lesions size

Follow Non HCC Protocol

Features of chronic liver disease

Yes

Can Tolerate Major

surgery

Atypical features on imaging

percutaneous biopsy

No

> 5 cm Radiofrequency

Ablation(RFA)

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Standard Operating Procedure for Liver SOL – Non HCC

Non- HCC Protocol

Unresectable colorectal

primary or otherprimary

sitewith liver metastasis

Good Poor

Functional liver Remnant (FLR)>30%

Fit for major surgery

FLR<30%

Resection

Performance status

No Yes

Palliative

chemotherapy

Supportive therapy

Asymptomatic

benign lesions Symptomatic

benign and

premalignant

lesions

Intrahepatic

cholangiocarc-

inoma

Metastasis in

liver

Observe

Liver only mets with Resectable primary

colorectal ca and genitourinary malignancy

Surgery for primary malignancyand

5 FU based Chemotherapy for

colorectal ca

Chest XRay,

Serum.CEA

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Standard Operating Procedure for Liver Trauma

Liver trauma

Initial resuscitation Grouping and cross matching

Unstable Stable

Associated injuries requiring surgery (eg. Hollow viscus perforation)

Operating room CECT

Isolated liver injury

No contrast blush

Contrast blush present

Conservative management

ICU care

6 hourly hemoglobin estimation

Heart rate and blood pressure monitoring

Watch for compartment syndrome/ peritonitis

Watch for sepsis

Successful

Clinical deterioration Unsuccessful

Angioembolisation

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Standard Operating Procedure for Morbid Obesity

YES NO

Failure of surgery

BMI >40 kg/m2 or BMI >35 kg/m2 with an associated medical comorbidity worsened by obesity

Failed dietary therapy

Psychiatrically stable without alcohol dependence or illegal drug use

Knowledgeable about the operation and its sequelae

Motivated individual

Ambulating patient

Prader-Willi syndrome ruled out

Age group (> 18yrs & < 65 yrs)

Cardiovascular evaluation

• Pulmonary assessment - obstructive sleep apnea, reactive asthma, pickwickian syndrome

Renal function.

Musculoskeletal conditions

Diabetes control

Clinical examination for umbilical or ventral hernias

USG abdomen to R/O cholelithiasis

UGIE to R/O GERD, Barrett’s & Hiatal hernia

BMI > 50 (Super Obese)

MALABSORPTIVE PROCEDURE

1) Biliopancreatic diversion 2) Duodenal switch

RESTRICTIVE PROCEDURE

1) Sleeve gastrectomy 2) Roux en Y gastric byepass

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Portal hypertension

Complete Blood Count, Liver Function Tests, Kidney

Function Tests, UpperGI Endoscopy, Ultrasound abdomen,

Doppler Ultrasound portal axis

Present

Extrahepatic Portal Vein Obstruction (EHPVO)

Present Absent

Splenectomy and

introp portal

pressure

Computed

Tomogram(CT)portovenogra

m if portal venous anatomy

not clear or Portomesenteric

venous thrombosis suspected

or pseudoaneurysms in the

portomesenteric circulation

or if Rex shunt is planned

If portal pressure <12

cm H2O, Observe

Left portal vein > 3

mm in EHPVO

Rex shunt

If portal pressure> 12

cm H2O

Absent

Proximal Splenorenal

Shunt

NCP

F CLD

Chronic Liver Disease(CLD),Noncirrhotic Portal Fibrosis(NCPF)

Patient on chronic

endoscopic therapy

for varices

Moderated to massive

splenomegaly

Symptoms of

hypersplenism and

no Varices

Portal cavernoma

If varices

,endoscopic

therapy for

variceal

eradication

Diffuse splanchnic

venous thrombosis

Gastroesophageal

devascularisation

Compatible splenic

vein anatomy

Spenicvein not

available but patent

SMV or portal vein

Interposition mesocaval or

portocaval shunt

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No.

Issue No. 1.0






& Head

Standard Operating Procedure for Rectal Prolapse

Rectal Prolapse

Complete Blood Count, Liver Function Tests, Kidney Function

Tests, Examination in squatting position,

Clinical Features: mass protruding per anum, mucus discharge per anum,

difficulty in evacuation of stool, History of constipation, history of prolonged/

difficult labour

History of constipation

Laparoscopic mesh rectopexy

Absent Present

Laparoscopic anterior resection

and mesh rectopexy

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No.

Issue No. 1.0






& Head

Standard Operating Procedure for Surgical Obstructive Jaundice

Painless progressive jaundice

Associated with anorexia/weight loss

Short duration of symptoms

Suspect benign cause Suspect malignant

cause cause

No Yes

Initial investigation: liver function test and ultrasound abdomen

- To confirm obstructive nature of jaundice, to identify etiology (benign

or malignant), if malignant - level of obstruction (lower end or hilar) and

stage the disease

Choledocholithiasis Malignant lower end

obstruction and no evidence

of metastasis

Malignant hilar

obstruction

ERCP & stone extraction

followed by laparoscopic /

open cholecystectomy Or

laparoscopic / open

cholecystectomy with CBD

exploration

Follow treatment

algorithm for lower end

obstruction

Follow treatment

algorithm for malignant

hilar obstruction

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No.

Issue No. 1.0






& Head

Standard Operative Procedure for Malignant lower end obstruction

Malignant lower end

obstruction – periampullary

and pancreatic head carcinoma

Assess indications for biliary drainage

– cholangitis, severe malnutrition and

Total bilirubin > 15mg/dl

Dual phase CECT (Pancreatic protocol)

or MRI with MRCP for accurate

staging followed by ERCP & stenting

Side viewing endoscopy +/- biopsy

followed by cross sectional imaging

with CECT or MRI abdomen

Metastatic disease Locally advanced disease Rescetable disease

Palliative therapy -

metallic biliary stenting or

triple bypass

Pancreatoduodenectomy Neoadjuvant

chemotherapy therapy

and reassess with imaging

If resectable disease If unresectable disease

Yes No

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No.

Issue No. 1.0






& Head

Standard Operative Procedure for Malignant hilar obstruction

Malignant hilar obstruction

Assess for resectability using

Triple phase CT abdomen or MRI

with MRCP abdomen carcinoma

Rescetable disease Unrescetable disease

Palliative biliary drainage

ERCP and stenting if hilar confluence is patent,

PTBD if hilar confluence is not patent

Assess indications for biliary drainage –

cholangitis, severe malnutrition, Total bilirubin

> 10mg/dl and prolonged jaundice > 4 weeks

irrespective of bilirubin level

Assess future liver

remnant

Adequate > 40 % Inadequate < 40 %

Surgical resection Portal vein embolization

Yes No

Department Manual

DEPARTMENT OF SGE

JIPMER, PUDUCHERRY

Section No.

Issue No. 1.0






& Head

Standard Operative Procedure for Ulcerative colitis

Ulcerative colitis

Proctitis Mild to moderate

severity

Moderate to severe Complications

e.g: perforation,

massive

hemorrhage or

toxic megacolon

Aminosaliclic acid

(ASA) suppositories

Left sided Extensive

Oral 5- ASA

Response

Oral 5- ASA

maintenance

yes

NO

Oral steroids

NO

yes

Rectal 5-ASA

maintenance

Response

Taper steroids,

consider oral 5-

ASA

Cyclosporine or

infliximab

NO Yes

Urgent surgery: total abdominal

colectomy and end ileostomy

ileal pouch anal anastomosis

(IPAA) at later stage

Refractoriness/ dependence/ toxicity

to medical therapy or carcinoma/

DALM

Surgery: Total

proctocolectomy and ileal

pouch anal anastomosis

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