CORE PROCEDURES Flashcards

Question

Ileostomy closure

Answer 1

Incise 1-2 mm of skin around ostomy Dissect down to the bowel wall, freeing the bowel from abd wall Use a 80 mm blue linear stapler on antimesenteric border and a TA-60 blue stapling device to close the opening in the common channel Drop bowel back into abdomen, loosely close stoma site

Answer 2

ID desired area of resection and come through mesentery right under bowel Transect bowel with 60 mm blue stapler maintaining a bias to avid corner ischemia Excise mesentery, harvest LN if CA operation Excise antimesenteric corners of the stapler lines Introduce a 60 mm blue GIA stapler and fire along antimesenteric border, ensure mesentery not involved, ensure hemostasis of staple lines Offset staple lines and close common enterotomy with TA 60 stapler Palpate for patency of anastomosis Close mesenteric defect

Answer 3

Ignore dead bowel, embolectomy/thrombectomy first Lift transverse colon, find middle colic and follow it to SMA Heparinize (80 U/kg) OBtain prox and distal control Make transverse incision (embolectomy) or longitudinal incision (thrombectomy) in soft portion of SMA Pass #4 fogarty until clear of clot x 2 consecutive passes SHoot completion angio; if still occlusion then bypass from infrarenal aorta or R common iliac a to arteriotomy site Close arteriotomy with interrupted 4-0 prolene (if embolectomy) or vein/graft patch (if thrombectomy)

Answer 4

Preop foley placement to decompress bladder Infraumbilical hassan, 5 mm supraumbilical, 5 mm LLQ Free appy from surrounding structures Make mesoappendiceal window Take appendix with bowel load on linear stapler Take mesoappendix with vascular load on linear stapler Evaluate for hemostasis of staple lines Remove appy with spcimen bag

Answer 5

Incise white line of Toldt and mobilize colon from RP attachments Mobilize hepatic/splenic flexure PRN ID ureter, reflect laterally Ligate vessels (usually need to take 2 named for formal resection) at base of mesentery, take lots of LN (goal = at least 12)

Answer 6

Lithotomy position Transect TI with linear stapler Incise white line of Toldt on R, mobilize hepatic flexure Enter lesser sac, take down splenic flexure Incise white line of Toldt on the L, connect lateral mobilization Findboth ureters and retract laterally Ligate vessels and take mesentery Dissect clearly distal to the rectosigmoid junction at sacral promentory or where teniae coalesce, excising surrounding mesorectum Transect rectum with contour or TA stapler Sew anvil into TI End to end EEA stapler anastomosis Completion proctoscopy with air leak test

Answer 7

Preop stoma site marking, avoiding belt line and any other skin folds ID piece of colon for creation of ostomy, divide bowel or mark proximal and distal aspects of bowel Excise 2 cm circular piece of skin along rectus abdominis muscle Muscle split and make cruciate incision in anterior rectus sheath t accomodate 2 finger breadths Exteriorize colon and excise the staple line, create ostomy along tenia Full thickness bites to dermis with 3-0 vicryl, no brooke size and apply ostomy appliance

Answer 8

Lithotomy position Lower midline incision ID anddissect out distal sigmoid stump TAke down the ostomy by incising 1-2 mm of skin around stoma and separate from abdom wall Mobilize splenic flexure if necessary Freshen edges by restapling EEA stapler anastomosis: sew anvil in proximally, put stapler through anus PErform completion proctoscopy and leak test

Answer 9

Mark out 1 cm margins around tumor (if >2 cm, need APR) Remove skin down to SQ flap Reconstruct with V-Y advancement flap

Answer 10

Enema Prone jackknife Bilateral pudendal nerve blocks and 4 quadrant perianal block Use Goodsalls rule and fistula probe/hydrogen peroxide injection to ID fistula tract Fistulotomy (intersphincteric or transphincteric involving <1/3 internal sphincter): cut down on fistula probe, currett out epithelialized tract Draining seton (transphincteric >1/3 internal sphincter): place a seton by tying vessel loop to probe and pulling it through then tying it to itself with silk suture

Answer 11

Enema Prone jackknife ID intersphincteric groove by palpation on R side of anal canal Incise mucosa overlying intersphincteric groove Develop intersphincteric plane with hemostat Divide internal sphincter distal to proximal towards dentate, division of muscle to heihgt of fistula Close mucosal defect with 3-0 vicryl

Answer 12

Prone Jackknife Elliptical incision overlying area of maximal induration Send for culture (aerobic, anaerobic, gram stain) Hemostat/irrigation to divide any loculations Evaluate for hemostasis Pack wound

Answer 13

Enema Prone jackknife Locate 3 hemorrhoidal bundles: R anterior, R posterior, L lateral Load band on device, target vascular bundle just proximal to the hemorrhoid and fire above dentate line *dont do more than one column)

Answer 14

Enema Prone jackknife Elevate submucosal space with local Incise perianal skin and undermine hemorrhoid complex, leaving sphincter down Place clamp across hemorrhoid complex, sharply remove hemorrhoid 3-0 vicryl suture at vascular bundle, run up the clampt owards dentate line, remove clamp Reapproximate mucosa by running 3-0 vicryl back towards proximal hemorrhoidal complex Reapproximate anoderm with another 3-0 vicryl, leaving edge open for easy drainage

Answer 15

Prone jackknife Acetic acid Cut larger condyloma with scissors, mark location of biopsy for pathology Fulgurate smaller collections with bovie

Answer 16

Place on monitor, pre-oxygenate with 100% O2 Fentanyl/versed for sedation Insert bronchoscope, ID carina and R/L mainstem based on tracheal rings Inject 10 cc saline at site of interest Aspirate into leukin trap and send lavage for aerobic, anaerobic, fungus, cytology

Answer 17

Place on monitor, preoxygenate with 100% O2 Fentanyl/versed for sedation Insert bronchoscope, ID carina and R/L mainstem based on tracheal rings ID RU (3), middle (2) and lower (5) segments ID left upper (super/lingular, 5) and lower (5) lobe segments Bx/lavage any areas of concern

Answer 18

Left lateral decubitus with knees flexed towards chest Place on monitor, pre-oxygenate with 100% O2 Fent/Versed for sedation Confirm colonmoscope functioning (light, suction, irrigation) External anal exam and DRE Insert scope and advance all the way to cfecum which is confirmed by identification of TI and appendiceal orifice Withdraw for at least 6 minutes, bx any areas of abnormality and tattoo any areas concerning for malignancy Retroflex in rectum to evaluate for hemorrhoids/masses in anal canal

Answer 19

Pisitoion pt on left side, partially elevated head of bed Place on moniotor, pre-oxygenate with 100% O2 Fent/Versed for sedation Confirm endoscope functioning (light, suction, irrigation) Place bite block device Pass scope by staying in midline, identifying oropharynx and following tongue down ADvance scope all the way to 2nd portion of duodenum (right and downward motion at pylorus) then withdraw slowly RAndom bx in antrum to rule out H pylori, any other areas of concern, retroflex to evaluate hiatus for HH/ulcers/masses Desufflate stomach Withdraw endoscope throuigh esophagus slowly, Barretts bx - 4 quadrants, 1-2 cm travel

Answer 20

Pick nare that moves air better Check scope Anesthetize with viscous lidocaine Pass scope down nose to pharynx with patient in sniffing position E xamine cords as patient phonates and coughs

Answer 21

Enema Prone jacknknife Perform external anal exam and DRE Check scope (light source, insufflation) place obturator in scope, lubroicate Introduce scope, insufflate and look for suspicious lesions circumferentially

Answer 22

Attempt to express DC in OR Make periareolar incision 1/3 circumference encompassing quadrant of discharge Insert lacrimal duct prbe into discharging duct Excise duct containing probe with margin from just below the nipple dermis into the deep breast tissue (4 cm down) If no single secretion filled duct identified, entire subareolar central duct complex must be excised (4 cm down)

Answer 23

Extend neck Baseline PTH level Collar incision 1 fingerbreadth above sternal notch SUbplatysmal flaps, separate straps in midline and dissect them off the thyroid Ligate middle thyroid vein Look for parathyroid glands, close to inferior thyroid artery and RLN (superior deep/lateral to RLN and inferior anterior/medial to RLN) Pre-excision PTH level Excise adenoma, check PTH at 5 min and 10 min post excision for goal 50% drop If 4 gland hyperplasia: remove 1/2 of first gland, remove 2 full glands,return to remaining 1/2 gland to confirm not ischemic, then remove remaining full gland Autotransplantation morcellate remaining parathyroid and place into SCM or brachioradialis muscle

Answer 24

Extend neck Collar incision 1 FB above sternal notch Subplatysmal flaps, separate straps in midline and dissect them off the thyroid Ligate middle thyroid v Take superior pole vessels Roll su[perior thyroid lobe to identify RLN Take inferior pole vessels once RLN identified Identify and preserve parathyroids by performing capsular dissection Divide ligament of berry/isthmus and remove thyroid from the airway Repeat on other side

Answer 25

ultrasound the thyroid parenchyma, central and lateral neck

Answer 26

Prone, jackknife Isolate the sinus tract Ellipse excision down to the sacral fascia Allow to heal by secondary intention versus flap or off midline closure

Answer 27

Hook up pressure line to 20G needle or use Stryker system Zero the system Stick diff compartments to get pressure readings

Answer 28

SVT Afib with RVR 100J up to maximum manufacturer dose

Answer 29

Pulseless vtach, vfib 360J if monophasic or 200J if biphasic

Answer 30

Preoxygenate with 100% O2 Induction: etomidate 0.3 mg/kg Paralytic: succinylcholine or rocuronium 1 mg/kg Use glidescope to ID epiglottis, vocal cords Place ETT (7 mm) Confirm approp placement with ET CO2, condensation in ETT, bilateral chest rise and breath sounds

Answer 31

US guidance to vavoid epigastrics Clean RLQ Send for PMNs, gram stain, albumin and glucose If large volume rememer albumin

Answer 32

RIJ cordis Test balloon Inflate and float swan Look for waveform changes: RA is short amplitude, RV is wide amplitude, PA is dicrotic, wedge is short amplitude Post procedure CXR (PACP should look like smile along heart silhouette)

Answer 33

Sit pt up with elbows resting on a table Entry point is right below inferior angle of scapula Send fluid for cx, gram stain, cytology, pH, glucose, LDh, protein Exudate: high protein/LDH i.e. infection or malig Transudate: low protein/LDH i.e. CHF

Answer 34

Right medial visceral rotation (Cattell Brasch) Compress IVC proximally and distally with large spongesticks Systemic vs local heparinization if hemodynamics allow Suture repair injury with 3-0 prolene or place interposition graft (dacron)

Answer 35

Get prox control by clamping distal thoracic aorta through hiatus through pars flaccida Left medial visceral rotation (mattox) Progressively move proximal clamp down to site of injury Suture repair with 2-0 prolene or place interposition graft (dacron) Temporary abdominal closure to re-evaluate bowel

Answer 36

Intraperitoneal or concomitant pelvic injuries: 2 layer absorbable suture repair (inner vicryl, outer PDS), foley catheter drainage

Answer 37

cut inferior pulm ligament Open pericardium longitudinal to phrenic n deliver heart into open chest occlude hole vs definitive repair suture repair with 4-0 prolene pledget sutures, horizontal mattress to prevent coronary a occlusion Ligate lacerated coronary aa Mediastinal drainage/chest tubes

Answer 38

Position pt with neck extended Incision over anterior border of SCM Entrance into carotid sheath ID IJ vein, follow prox to identify facial vein, ligate for access to CCA Systemic vs local heparinization if HD allow ID and occlude carotid vessels: ICE Do thrombectomy with #3 fogarty until no clot returns x 2 consecutive passes Bovine pericardium patch repair with 5-0 prolene Unclamp ECI Post procedure doppler of all branches of carotid (common, internal, external) Leave drain

Answer 39

Kocherize duodenum Assess injury: easy to access, hard to access, or near transection If easy: suture closed transversely in 2 layers with inner PDS and outer silk, interrupted If hard: open duodenum and repair from inside as above if hole is in a difficult spot Near transected: try to bring together end to end , duodenostomy for controlled fistula or pyloric exclusion with GJ anastomosis and enteral feeding tube placement

Answer 40

Anti fungals, abx Cervical: left chest Mid esophagus: R chest 4-6th intercostal space Distal: L chest 7th ICS Medialize lung by taking down inf pulm ligament Open pleura over healthy esophagus, perform myotomy to evaluate extent of mucosal injury, debride edges of perf STent esophagus with NG tube Close defecti n 2 layers of absorbbale suture over NG tube Buttress with strap mm, pleura, pericardium or intercostal muscle Place mediastinal/chest drains If unable to repair, consideration for diverting spit fistula and enteral feeding tube

Answer 41

Enter abdomen with midline lap from xiphoidto pubic symphysis Eviscerate bowel and evacuate hematoma Pack all 4 quadrants Obtain hemostasis Run bowel from LoT to rectum Evaluate both diaphragms, anterior/posterior aspect of stomach, duodenum Control spillage/contam Inspect all zones (zone 2: open if penetrating, zone 3: open if penetrating or expanding)

Answer 42

Lateral incision one thumb in front of and below fibula to lateral malleolus ID intermsucular septum separating anterior and lateral compartments Create H-incision to open anterior and lateral compartments, presrving superficial peroneal nerve Medial incision one thumb behind and below tibia to medial malleolus Take care to preserve gr saph v Incise superficial fascia, retract gastrocnemius muscle laterally Take down attachments of soleus muscle to posterior aspect of tibia to release deep compartment

Answer 43

Volar/flexor compartment: biceps groove to antecubital fossa, S incision across antecubital fossa down to carpal tunnel, incise carpal tunnel with extension to palm Dorsal/extensor comp[artment: straight lin down to hand

Answer 44

Subxiphoid cardiac RUQ (morrisons pouch) LUQ suprapubic (pouch of douglas)

Answer 45

Incision along ant border of SCM Evaluate carotid sheath.- may ligate internal jugular v if injured, repair carotid a If injury to esophagus/trachea, must eval other side of neck for additional injuries on other side of esophagus and trachea Tracheal injury: 1 layer absorbable suture +/- trach below site of injury Esoph injury: 2 layer absorbable suture Interposition with strap muscles to minimize risk of TEF

Answer 46

Kocher maneuver Distal injury/transection distal to neck: distal panc/splenectomy Anterior injury: debridement iwth large drain placement If suspicion of ductal injury, wide drainage, post ERCP Feeding jejunostomy for any major head injuries

Answer 47

Options for temp control: pack, plug (omentum), pringle Pringle maneuver enter gastrohepatic ligament, place penrose or vessel loop around hepatoduodenal ligament Rule out retrohepatic venous bleeding before mobilizing liver Mobilize liver: divide round ligament, falciform ligament, coronary ligaments, triangular ligaments Options for hemostasis: cautery, argon beam, ligasure, 0-chromic suture with blunt needle tip, topical hemostastic agents, partial hepatectomy, angioembolization

Answer 48

Perform medial visceral rotation on left or right Incise gerota's fascia laterally and lift kidney out of its bed Palpate the contralateral kidney prior to nephrectomy Vascular repair artery if able with 6 mm ePTFE interposition graft Tie vein, suture ligate the artery, ligate the ureter between clamps as far distal towards bladder as possible

Answer 49

Splenic attachments shoudl already be divided from trauma Mobilize spleen towards midline Encircle hilum in hand taking care to exclude pancreatic tail Ligate splenic hilum with linear stapler vascular load Consdieration for drain placement Splenetctomy vaccines (meningococcal, strep pneumo, H flu) prior to discharge

Answer 50

Cut vents into extremity xray plastic cover/protector Place xray plastic above bowel Place kerlix and large drains above plastic Cover abdomen with Ioban Hook large drains up to wall suction

Answer 51

LAteral decubitus Singel lung ventilation Ports: mid axillary line 5th ICS and 5th ICS near lateral border of scapula Extract clot, wash out retained hemothorax, place 1-2 chest tubes

Answer 52

Consdier perc nephrostomy and getting out if HD unstable Try to repair primarily, dont over dissect periureteral fat, spatulate, repair over stent, use absorbbale suture (5-0 PDS) Lower 1/3: psoas hitch or boari flap middle 1/3: transureteroureterostomy (if other ureter not injured) upper 1/3: mobilize kidney for autotransplantation

Answer 53

Generous vertical groin incision starting 3 cm superior to inguinal ligament ,overp ulse or halfway between tubercle and ASIS Incise fascia lata and femoral sheath, find inguinal ligament, cut oinguinal ligament if you need to get prox control at iliac ID and control common femoral, superficial and profunda femoral Patch PTFE or interposition graft repair Swing sarotrius or gracilis over closure Post repair angiogram, pulse/doppler exam Consider shunt, fasciotomy

Answer 54

Enter Hunters canal/popliteal fossa REpair with contralateral GSV, do not ligate vein if can avoid Post repair angiogram, pulse/doppler exam Almost always perform fasciotomy

Answer 55

Incision below clavicle Cut pec muajor fascia and muscle ID ax vein, artery is SUPERIOR and DEEP

Answer 56

Biceps groove or antecubital fossa

Answer 57

sternotomy

Answer 58

left anterolateral thoracootmy

Answer 59

Elevate transverse colon cephalad, incise LoT for access to RP Place SB on R side of abdomen, sigmoid to left lateral side ID L renal V to ID infrarenal aorta Expose common iliac/femoral vessels depending on landing zone Heparinize (80 U/kg) OClamp infrarenal aorta, the ncommon iliac vessels Open aneurysm sac, evacuate any thrombus, oversew lumbar vessels Place straight or bifurcated Dacron tube graft, sew with 3-0 prolene, flush prior to completing Reimplant IMA if back bleeding pressure is less than 40 mm or if pt has had previous colon operation Chekc bowel viability Plapate femoral/distal pulses Close aneurysm sac and RP over graft

Answer 60

Confirm adequate anatomy: diameter <32 mm, landing zone 10-15 mm, angulation <60 degrees, adequate iliac vessel diameter Obtain access in bilateral femoral a with US, place closure devices and sehaths Heparinize with 80U/kg Use ocmmerically available sheath and measurement system and deploy graft, use additional iliac extensions as necessary Perform balloon angioplasty of proximal attachment zone, graft overlap sites, and distal attachment zones Perform completion angiogram to rul e out endoleaks Check distal pulses

Answer 61

Incise 10 cm inferior to tibial tuberostity, anterior flap is 2/3 leg circumference, make big posterior flap Divide muscles, expose fibula 3 cm above incision ID and divide anterior tibial neurovascular bundle in the lateral leg ID and divide posterior tibial and peroneal vessels in medial leg Saw the tibia and fibula Use amp knife to cut gastroc and soleus muscles in tapered fashion on posterior flap

Answer 62

Fish mouth, mid thigh Ligate GSV in inner thigh Ligate femoral vessels medially Expose femur 10 cm prox to incision with periosteal elevator Ligate sciatic nerve in the posterior thigh Divide femur 10 cm above skin incision

Answer 63

Make bilateral groin icnisions Isolate CFA, SFA and profunda femoral aa bilaterally Midline laparotomy, elevate T colon cranially to incise LOT for access to aorta Isolate infrarenal aorta Heparinize (80 U/kg) Clamp infrarenal aorta proximally and distally Sew graft to side of aorta with 3-0 prolene Tunnel bifurcated graft under ureters along native vessels Obtain proximal and distal control of bilateral common femorals nad sew to the bifurcation bilaterally Check distal pulses

Answer 64

Should be heparinized For LE , start with standard groin incision to access CFA Obtain prox and distal control Make transverse arteriotomy for embolus and longitudinal for thrombus Pass a #4 fogarty as far distal as it will go, then inflate balloon and withdraw, repeat until no clot x 2 consecutive passes Close arteriotomy with interrupted 6-0 prolene sutures if embolus, graft repair if thrombus, flush the closure prior to completion Perform completion angiogram, access more distal vessels if ongoing embolus/thrombus

Answer 65

Transverse incision 2 cm inferior to clavicle Bilateral vertical groin incision 2 FB lateral to pubic tubercle Split pectoralis major muscle to get down to ax vascular bundle, expose axilalry artery, control with vessel loops Isolate common, superficial and profunda femoral aa with vessel loops (if bypassing infection go lateral to sartorius and isolate distal profunda artery) Tunnel 8 mm ePTFE graft Heparinize (80U/kg) sew in axillary an dfemoral ends of graft with 5-0 prolene Check distal pulses

Answer 66

Vertical groin incisions 2 FB lateral to pubic tubercle Isolate common femoral, superfiical femoral, and profunda femoral aa with vessel loops Tunnel 8 mm PTFE graft suprapbuically Heparinize (80U/kg) Sew in graft with 5-0 prolene to side of femoral aa, flush before unclamping Check distal pulses

Answer 67

Vertical incision 2 FB lateral to pubic tubercle Medial thigh incision just above knee, open fascia overlying popliteal space Separate popliteal a from vein and tibial n Harvest GSV from same side, ligating tributaries Reverse it and leave path of vein in situ Heparinize Prox and distal control fo femoral artery, sew in GSV graft to side of femoral artery with 5-0 [prolene Prox and distal control of popliteal artery, sew in graft to side of popliteal artery with 6-0 prolene Flush prior to completing anastomosis Perform completion angiogram

Answer 68

Prep both groins and entire affected leg Dissect out inflow, almost always CFA via standard groin incision Dissect out distal target - medial calf for peroneal and posterior tibial aa, lateral calf for anterior tibial a HArvest GSV, ligating any tributaries Heparainize SEw to side fo femoral artery with 5-0 prolene, sew to side of distal vessel with 5-0 prolene PErform completion angiogram

Answer 69

Target refluxing vessel with duplex US Inject foam sclerosant to destroy endothelium of target vessel

Answer 70

Access femoral ve Place 8.5 Fr sheath Advance catheter and perform cavogram to ensure patency of IVC and ID renal vv Advance sheath to region of planned deployment, below lowest renal vein ADvance filter within sheath to sheath end Draw sheath back to expose filter and release filter hook Perform completion cavogram Can also perform through IJ vein

Answer 71

Perform small cutdown on source of reflux Anteromedial groin incision - saphenofemoral junction is just medial to femoral a below groin crease Posterior calf - lesser saphenous at saphenopopliteal junction Place external stripper through saphenous system, have it exit through counter incision, attach stripper head distally, strip GSV from groin to knee using inversion technique Remove clusters of varicose veins through stab evulsion technique.- tiny stab incision, vein hook

Answer 72

Use US to find and mark brachial artery and target vein (cephalic is lateral to biceps or basilic is medial) Transverse incision below elbow in antecubital fossa Isolate 4 cm of target vein Divide bicep aponeurosis in cruciate configuration Separte brachial artery from paired veins and isolate 3 cm Select and size a tapered 4 to 7 mm PTFE graft, sew 4 mm end to arterial inflow (prevents steal), 7 mm to venous outflow Use semicircular tunneling device to tunnel graft in subcutaneous tissue distally to create an oval tunnel Heparinize Perform venous anastomosis: clamp, venotomy, end to side 6-0 prolene (use 7 mm end of the graft) Perform arterial anastomosis: clamp, arteriotomy, end to side 6-0 prolene, use 4 mm end of the graft Remove clamps, check for thrill/bruit in AV graft Palpate distal radial and ulnar pulses

Answer 73

Start with non dominant arm Cephalic vein is on thumb side and goes all the way up lateral arm US the UE to rule out arterial insufficiency and determine adequate diameter of vessels Use US to mark distal forearm course of radial a and cephalic v (or whatever targeted vessels) 5 cm longitud incision between radial a and cephalic v Isolate cephalic v for 5-6 cm, ligating small branches Isolate radial a for 2-3 cm Heparinize Ligate cephalic vein distally, put clamp on it proximally Proximal and distal radial a control, 2 mm arteriotomy, end to side anastomosis with 7-0 prolene Remove clamps, feel for palpable thrill and audible bruit in fistula Check distal radial and ulnar pulses

Answer 74

Select size -36 Fr for trauma, 20 Fr for PTX Abduct arm ID nipple or IMF for access to 4th/5th intercostal space Anesthetize SQ tissue and periosteum Enter at superior aspect of lower rib to avoid intercostal neurovascular bundle Post proc CXR

Answer 75

Lateral decub, single lung ventilation on opposite side of interest ID 4th ICS Anterolateral thoracotomy from sternal border to midaxillary line Tie transected ends of internal mammary artery Divide inferior pulm ligament Explore chest Leave chest tubes

Answer 76

Lateral decub, single lung ventilation on opposite side of interest Ports in middle (7th space), anterior (5th space) and posterior axillary (5th space) lines Explore chest Leave chest tubes

Answer 77

Lateral decub with lesion side up, single lung vent other side Incision extends from medial scapular border posteriorly to anterior axilalry line just below the nipple following contour of 5th ICS Grasp lung and wedge it out for a biopsy Lobectomy: 1st dissect out appropriate pulm vein nand ligate it iwth vascular stapler, dsisect out pulm a and divide with vascular stapler, then dsisect out and divide lobar bronchus and divide with green laod 4.5 mm stapler Take lymph nodes with specimen (9, 11-14) Perform saline leak test, re-insufflatel ung under direct visualization Leave chest tubes

Answer 78

Lateral decub with lesion side up, single lung vent other side Ports in middle (7th space) anterior (3rd space) and posterior axillary (5th space) lines Grasp lung and wedge it out for biopsy Lobectomy: 1st dissect out appropriate pulm vein and ligate with vascular stapler, dissect out pulm a and divide with vascular stapler, the ndissect out and divide lobar bronchus and divide with green load 4.5 mm stapler TAke LN with specimen (9, 11-14) Perform saline leak test, reinsufflate lung under direct visualization LKeave chest tubes

Answer 79

8 cm incision over xiphoid Excise xiphoid process if needed Finger dissect into retrosternal space to identify pericardium Grasp pericardium with tonsil/clamp Sharply open pericardium aspirate, break loculations with finger, biopsy the pericardium Insert tube into pericardial space through separate stab incision Inguinal hernia repair

Answer 80

Incise over external ring Open lateral aspect of EO and carry towards external ring Only divide ext ring if you need exposure Gently dissect out the cord with blunt moves parrallel to direction of cord Pass hemostat behind cord to elevate hernia and cord into operating field Incise cremasteric muscles overlying the cord Incise the internal spermatic fascia Find and gently hold the hernia sac anteromedially, dissect spermatic vessels and vas deferns off the hernia sac Dissect towards internal ring until preoperitoneal fat at neck is exposed Twist the sac, do high ligation with transfixing 5-0 vicryl suture, excise redundant sac, allow prox sac to retract underneath external ring Clsoe any attenuated ext oblique muscle or divide ext ring Return testicle to scrotum

Answer 81

opening the fistula tract, performing a curettage of it, suture closing the internal os, and advancing the mucosa, submucosa, and muscle from proximal to distal to cover the internal os. This can result in seepage and the patient may feel like they’re experiencing incontinence or a wet-anus but this will resolve the fistula in most cases.

Answer 82

when you make a curvilinear incision along the fistula tract, curettage the tract, and ligate the fistula in between the internal and external sphincters. You then close the external os and reapproximate the mucosa over the fistula tract. There’s a small chance of incontinence with these as well so I would talk to the patient about that.

Answer 83

3-5 cm paramedian skin incision (minimizes risk of pericatheter leak and hernia) 2-3 cm incision through anterior and posterior rectus sheath to reach peritoneum Purse string of 4-0 absorbable suture placed around peritoneal opening Stylet placed into catheter and inserted into peritoneal cavity, directed to pelvis to the R side of rectum Purse string around catheter, BELOW Dacron cuff, and fascia closed around Cath with interrupted NONabsorbable suture SQ tunnel amde, catheter is tunneled, leaving superficial Dacron cuff 1-2 cm deep to skin Catheter flushed with heparinized saline

Answer 84

Meticulous inspection of the diaphragm intraoperatively is necessary. Debridement of devitalized tissue Small defects can be repaired primarily with nonabsorbable suture, using interrupted, running, or figure-of-8 suture techniques. Larger defects may require repair with prosthetic mesh (consider biologic) Chest tube placement (minimize postop complications of PTX or effusion)

Answer 85

Both open and laparoscopic parastomal hernia repair adhere to the general principles of hernia repair: Reduction of the hernia contents Excision of the hernia sac Tension-free closure of the fascial defect (if possible) Possible mesh reinforcement Mesh placement, in a retrorectus or intraperitoneal underlay position, reduces recurrence rates. In emergent or contaminated cases, suture repair alone with or without absorbable/biologic mesh placement may be the preferred option. A "keyhole" mesh can be fashioned, allowing passage of the stoma conduit through the mesh. Alternatively, a modified Sugarbaker-type mesh repair can be used, where the ostomy is lateralized using a noncircumferentially secured underlay mesh.

Answer 86

In a frankly contaminated field, placement of a permanent mesh should be avoided. Primary repair should be performed or a biologic or absorbable synthetic mesh should be used. The best outcome in terms of reducing hernia recurrence involves placement of a permanent prosthetic mesh. Synthetic absorbable and biologic meshes are most often used in contaminated fields where infection is a concern but are associated with higher recurrence rates. Mesh reinforcement can be performed as an onlay, sublay, or underlay repair. In general, sublay or underlay mesh placement has been associated with lowest hernia recurrence rates.

Answer 87

A preperitoneal or intraperitoneal approach is best (either laparoscopic or open). Reduction of hernia contents and sac The obturator foramen can be opened posterior to the nerve and vessels. Repair with placement of a pre-peritoneal mesh

Answer 88

Can be approached through trans-abdominal and/or perineal Reduction of sac and contents Repair with suture (for small defects) or mesh (for larger defects)

Answer 89

The anterior release involves creation of subcutaneous flaps, division of the external oblique aponeurosis lateral to the semilunar line, and development of the plane between the external oblique aponeurosis and the internal oblique muscle laterally. Mesh reinforcement can then be placed in an underlay or overlay position.

Answer 90

The posterior release involves opening the retrorectus space medially and creating the posterior plane between the rectus muscle and the posterior rectus sheath. The posterior rectus sheath is then incised again just medial to the laterally perforating neurovascular bundles. The underlying transversus abdominis muscle can be divided (TAR), and dissection is carried laterally to mobilize the transversalis fascia and peritoneum off of the overlying muscle.

Answer 91

Perform a cholangiogram. After establishing the stone burden, replace the cholangiogram catheter with either a basket extraction implement or choledochoscope. Use glucagon to relieve sphincter pressure along with transcystic flushing of the duct with saline to force debris into the duodenum. In cases of stone impaction, use Fogarty balloon catheters to help free the stones. Place the retrieved stones in a safe spot in the abdomen and eventually in a specimen bag with the gallbladder.

Answer 92

Perform a cholangiogram. Forcefully flush through the transcystic catheter to distend the CBD. Make a distal, vertical, supraduodenal choledochotomy with sharp scissors or hook cautery on cut mode. Use a cholangiogram catheter to flush the stones. Perform a choledochoscopy with a flexible scope. Retrieve the stones using a basket retrieval device through the working port of the choledochoscope. In cases of stone impaction, use Fogarty balloon catheters to help free stones. Close the choledochotomy primarily or over a T tube at least 14F in size using absorbable monofilament suture.

Answer 93

Perform an extensive Kocher maneuver such that the area of the ampulla can be palpated. Make a distal, vertical, supraduodenal choledochotomy approximately 1.5 cm in length. Pass Fogarty catheters superiorly to extract stones from the common hepatic duct and inferiorly through the ampulla to extract CBD stones. Irrigate generously with saline. Ensure that the CBD is clear of stones using either choledochoscopy or a cholangiogram. Close the duct primarily or over a T tube at least 14F in size.

Answer 94

Perform an extensive Kocher maneuver. Make a transverse or longitudinal duodenotomy on the lateral duodenal wall at the junction of the lower one-third and upper two-thirds of the duodenum. Identify the papilla. Cut the ampullary sphincter in the 11 o'clock position on the papilla using cautery or scissors. Extend this to include the entire common tract of the sphincter of Oddi. Extract all stones. Suture the wall of the CBD to the duodenal mucosa using interrupted fine absorbable sutures. Close the lateral duodenotomy.

Answer 95

Supine (esp if tumor closer to portal-SMV) vs modified "lazy" right lateral decub Thorough dx lap --> MIS or open Enter lesser sac via dividing gastrocolic ligament, ensuring adequate control of the short gastric vessels with clips, electrocautery, or ultrasonic scalpel. If the spleen is to be removed with the distal pancreas specimen, the short gastric vessels are similarly divided to allow splenic mobilization. The stomach is retracted anterosuperiorly toward the abdominal wall. The splenocolic ligament is similarly divided to allow caudal retraction of the transverse colon and splenic flexure. The distal pancreatic body should be entirely visualized at this time. The distal aspect of the gland is then mobilized from the posterior retropancreatic fat using a combination of blunt dissection and bipolar electrocautery or ultrasonic scalpel, either from lateral to medial or medial to lateral. The splenic vein is directly posterior to the pancreas and comes into view before the artery as the gland is dissected posteriorly. Early preparation of the transection plain is critical if urgent vessel ligation is required in the event of hemorrhage during dissection. The splenic artery, vein, and pancreas may be ligated/transected in any order as dictated by the flow of the operation and anatomy. The splenic vessels should be ligated with vascular stapler or combination of clips and ties, and the vessel stumps should be kept as short as possible; long vascular stumps increase the risk of thrombosis or rupture. The pancreatic gland itself is transected using a stapler, or energy device, with or without oversewing or use of an omental pedicle flap over the stump. The distal pancreas (with or without spleen) specimen is then removed. For laparoscopic procedures, this is typically performed via an endoscopic retrieval bag and enlargement of a laparoscopic port site or Pfannensteil-Kerr incision. The surgical bed is then inspected for adequacy of hemostasis, and the choice of operative drain placement is at the discretion of the operating surgeon.

Answer 96

Use a midline incision, which is optimal for exposure when the spleen is ruptured or massively enlarged. Understand that a left costal margin incision is preferred in most elective procedures. Mobilize the spleen by dividing ligamentous attachments, beginning with the splenocolic ligament. Enter the lesser sac. Realize that in patients with significant splenomegaly, early ligation of the splenic artery along the superior border of the pancreas is an option and may be preferred. This allows safer manipulation of the spleen and dissection of the hilum. This allows for some shrinkage of the spleen itself. This provides an autotransfusion of red blood cells and platelets. Incise the lateral peritoneal attachments, most importantly the splenophrenic ligament, and gently develop a plane deep to the spleen and tail of the pancreas. Next perform individual ligation and sequential division of the short gastric vessels. Identify the tail of the pancreas and protect it from harm. The tail of the pancreas often lies within 1 cm of the splenic hilum. Ligate the splenic artery and vein before dividing them. Remove the spleen. Look for accessory spleens. Common locations are the splenic hilum, splenic pedicle, greater omentum, the tail of the pancreas, and splenocolic ligaments. Close the abdomen without drainage.