Core Procedures

Question 1

abdominal exploration

Answer 1

midline incision
run the small bowel from ligament of treitz to ileocecal valve
inspect the colon, stomach, spleen, etc

further exploration will be guided by indication and findings in OR

Question 2

PD catheter placement

Answer 2

1. access peritoneal cavity
2. insert catheter/sheath
3. Place proximal cuff in the pre-peritoneal space.
4. Tunnel catheter to exit site
5. Place the distal cuff in subq
6. Close the abdomen.
7. Flush the catheter and allow contents to run out.

Question 3

Diaphragmatic hernia

Answer 3

1. obtain laparoscopic access
2. examine entire diaphragm and debride devitalized tissue surrounding defect
3. Repair small defects with nonabsorbable suture
4. Use prosthetic mesh for larger defects

Question 4

inguinal hernia repair - mesh

Answer 4

1. oblique incision two finger breadths above inguinal ligament
2. incise external oblique in direction of fibers
3. Dissect sac off cord structures, encircle them (in men). Ligate round ligament in women.
4. Reduce hernia into ab domen. Ensure to Identify and preserve the ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve.
5. Secure polypropylene mesh to the pubic tubercle medially, shelving edge of the inguinal ligament inferiorly, and conjoined tendon (lateral portion of the rectus sheath) superiorly.
   6.Reapproximate external oblique and close skin.

Question 5

inguinal hernia repair - tissue (or femoral)

Answer 5

McVay repair
Same as lichtenstein but affix conjoint tendon to cooper’s ligament rather than using mesh.
1. oblique incision two finger breadths above inguinal ligament carried down through subq tissue to external oblique
2. incise external oblique in direction of fibers -protect ilioinguinal nerve
3. Dissect sac off cord structures, then encircle them (in men) before reducing contents into abdomen. Ligate round ligament in women.
4.Identify and preserve the ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve.
5 make relaxing incision in the anterior rectus sheath.
6. suture the conjoint tendon to Coopers ligament with interrupted sutures beginning at the pubic tubercle and progressing laterally.
7. start transition stitch at femoral canal to incorporate the conjoint tendon, cooper’s ligament, the femoral sheath, and shelving edge of the inguinal ligament.
8. continue with remaining sutures placed between the conjoint tendon and the inguinal ligament.
9.Reapproximate external oblique and close skin.

Question 6

axillary node dissection

-uncertain if core procedure

Answer 6

Define the lateral pec major, latissimus dorsi, axillary vein
Remove all axillary nodal tissue at stations I and II with preservation of long thoracic, thoracodorsal nerves and intercostobrachial if possible
Place closed suction drains

Question 7

ventral hernia (open)

Answer 7

1. enter peritoneal cavity, lyse adhesions, define fascial edges
2. retromuscular dissection, close posterior sheath
3. place mesh in retromuscular space
4. +/- drains in anterior fascial layer, close anteiror sheath
5. +/- subq drain if large subq flaps are made

Question 8

ventral hernia (lap)

Answer 8

1. enter peritoneal cavity, lyse adhesions, reduce hernia
2. measure defect and select permanent mesh with > 4cm overlap on each side w/antiadhesive coating on bowel side
3. affix mesh

Question 9

laparoscopic cholecystectomy

Answer 9

1. obtain laparoscopic access
2. dissect out cystic triangle
3. obtain critical view of safety: mobilize bottom 1/3 of cystic plate, visualize two tubular strucutre entering gallbladder with only liver parenchyma in background
4. clip and divide cystic duct and artery once view obtained
5. remove gallbladder with cautery and ensure hemostasis prior to removal

Question 10

intra-operative cholangiogram

Answer 10

1. lap chole until time to clip duct - then make partial ductotomy
2. insert cholagiogram cathetery, secure with clip
3. perform cholangiogram and look for contrast entering duodenum along with L and R hepatic duct systems withotu filling defects
4. if ducts do not fill - morphine to contract sphincter
5. if distal stone - flush with cholagiocatheter, 4fr fogarty to retreive, fluor basket retreival, glucagon to open sphincter
6. finish chole once duct clear

Question 11

cholecystostomy tube

Answer 11

1. May approach open or laparoscopically; CT/US guidance are the interventional approaches by IR only.
2. Place a purse-string suture around the fundus of gallbladder.
3. Scoop any gallstones that are easily visible.
4. Place a 20 or 24Fr cholecystostomy tube and secure purse string around tube.
5. Bring tube through abdominal wall and drain.

Question 12

T tube placement

Answer 12

Nonthermal injuries or <50%: repair over T tube. Cut 14Fr or 16Fr T tube arms short and cut them open longitudinally. Place into duct defect and secure with absorbable suture. Bring tube through skin.

Question 13

End to End Choledochocholedochostomy

Answer 13

1. Defects < 1 cm, distal to hilum and hepatic bifurcation
2. Mobilize the duct distally and proximally
3. Insert a transanastomotic T tube with exit via separate vertical choledochotomy
4. Primary repair over T tube

Question 14

Choledocho-duodenostomy

Answer 14

1. Distal bile duct injuries (if tension-free can be achieved)
2. Mobilize bile duct, kocher maneuver
3. Place a separate transanastomotic T tube with exit via separate vertical choledochotomy. Avoid blood supply at 3 and 9
4. Repair with primary anastomosis. Higher leak rate than roux-en-y

Question 15

Hepatico-jejunostomy

Answer 15

1. Dissect the porta and drop the hilar plate, creating avascular plane just anterior to hepatic ducts up to bifurcation/healthy tissue.
2. Anastomosis: end-to-side mucosa-to-mucosa anastomosis (or side-to-side if extending onto the left hepatic duct) with fine absorbable monofilament (5-0 PDS) to jejunal limb.
3. Create a jejuno-jejunostomy approximately 50 cm downstream from anastomosis.
4. Leave drains.

Question 16

CBD Exploration

Answer 16

1. Right subcostal incision, mobilize gallbladder, clip cystic artery, follow cystic duct down to expose CBD anteriorly and avoid the blood supply at the 3 o’clock and 9 o’clock positions
2. Complete the cholecystectomy and perform choledochotomy longitudinally about 1-2 cm distal to the cystic duct insertion site, towards the ampulla, place stay sutures
3. Either explore CBD (can place red rubber catheter and flush through that and advance to clear stones) or place T-tube. Avoid rigid instrumentation/extraction forceps. If the stone is extremely distal, do a transduodenal sphincterotomy a. Longitudinal duodenotomy over ampulla. Make a longitudinal incision with cautery over major papilla and anterior wall of CBD for 1.5 cm (can insert lacrimal duct probe). Suture duodenum and anterior CBD to each other with interrupted absorbable suture. Extract stone and close duodenum transversely to prevent stricture.
4. Choledochoscopy performed with 3 or 5-mm scope with continuous saline irrigation, wire basket advanced through scope
5. Place a 14- or 16-French T-tube: Cut “T” ends down to 2 cm on each side. Cut open the T longitudinally. Insert the T into the CBD. Suture in place with absorbable suture over the stent proximally and distally. Bring tube through abdominal wall. Perform drain study 6 weeks postop and slowly back out tube if the imaging is good (like a cholecystostomy tube)

Question 17

Hilar resection/reconstruction (advanced)

Answer 17

1. Make a hockey-stick incision or bilateral subcostal; divide round ligament/ligamentum teres and take down falciform. Leave 0-silk tie and use to retract inferior edge of liver to expose porta.
2. Divide lesser omentum to expose caudate and celiac nodes; watch for aberrant left hepatic artery. Examine caudate carefully.
3. Isolate distal CBD at level of pancreas (Kocher) and send frozen section to ensure negative distal margin. Dissect off of portal structures and perform cholecystectomy.
    Can extend to Whipple if needed to get negative distal margins.
    Prep a pringle during portal dissection
4. Lower the hilar plate to expose hepatic duct bifurcation. Send frozen sections to ensure negative proximal margins.
    Perform lymphadenectomy as you go.
    Can add right or left hepatectomy as needed: isolate inflow, mobilize liver, control hepatic veins, resect/divide parenchyma.
    Caudate lobectomy is usually required: dissect off of IVF and control perforating veins draining into IVC.
    Divdide proximal/distal ductal resection when frozen section is complete (don’t divide until resectability is confirmed).
5. Reconstruct with roux en y to each duct or hepatic duct

Question 18

Liver resection - intrahepatic cholangiocarcinoma

Answer 18

1. Evaluate for metastases  resectability: isolate inflow and outflow of planned resection to ensure that it can be completed. Use intraoperative ultrasound to localize and eval; perform portal dissection.
2. Perform partial hepatectomy if resectable: get inflow/outflow control and divide parenchyma.
3. Close abdomen.

Question 19

Gallbladder Cancer - Radical cholecystectomy (T1b or greater)

Answer 19

1. Staging laparoscopy.
2. Perform cholecystectomy (open) and carry dissection all the way to right hepatic artery and common bile duct.
3. Take all of the intervening fibrofatty tissue to get lymphadenectomy; carry over to porta/common hepatic artery node and skeletonize porta.
4. Resect segments IVb/V OR 1 cm rim of liver tissue around gallbladder fossa.
5. Control inflow with pringle maneuver as needed.

Question 20

hepatic abscess drainage (operative)

Answer 20

1. Obtain Laparoscopic access to abdomen and traingulate ports to LUQ.
2. Localize abscess using ultrasound if needed.
3. Drain, suction, send cultures.

Question 21

hepatic biopsy

Answer 21

1. Establish open or laparoscopic access (large port at umbilicus).
2. Triangulate additional ports according to location (right sided, LUQ usual).
3. Perform wedge or core needle biopsy with Tru-Cut needle; can use ultrasound guidance as needed for deeper lesions.
4. Ensure hemostasis.

Question 22

hepatic US intra-operative ( advanced)

Answer 22

1. Identify liver segments and anatomy.
2. Methodologically scan liver parenchyma to identify all lesions.
    Hepatic veins are thin-walled, portal veins are thick-walled
    Portal vein separates superior/inferior segments
    Cantile’s line: GB fossa to IVC, separates R and L liver (as does middle hepatic vein)
    Falciform separates L lateral and medial segments
    R hepatic vein separates R anterior and posterior sections
    R portal vein branches superior and inferior early on
3. Plan resection or ablation.
4. Check adequacy of vascular inflow/outflow in liver remnant.

Question 23

hepatic segmentectomy/lobectomy (advanceD)

Answer 23

1. Can be approached open or laparoscopically. Place ports or make incision.
2. Intraoperative ultrasound (see above).
3. Resect according to IOUS plan; use cautery, energy devices, clips, staplers.
4. Ensure hemostasis, check for bile leak and ensure good liver remnant perfusion.
5. Place drains selectively and close.

Question 24

distal pancreatectomy

Answer 24

1. Diagnostic laparoscopy.
2. Open lesser sac via gastrocolic ligament, divide short gastrics, mobilize splenic flexure.
3. Mobilize exposed pancreas from retroperitoneum, usually medial to lateral starting on inferior border. Watch for splenic vein posteriorly, splenic artery and celiac access cephalad/superiorly.
4. Splenic vessels are now exposed; divide if splenectomy is planned. Divide pancreas with stapler.
5. Remove distal pancreas +/- spleen in retrieval bag. Ensure hemostasis and close.

Question 25

pancreatic debridement

Answer 25

Step-Up Start with least invasive drainage (IR via retroperitoneal approach)  more invasive measures = minimally invasive retroperitoneal necrosectomy = VARD  ex lap if no improvement. VARD Video-Assisted Retroperitoneal Drainage 1. Retroperitoneal percutaneous drains by IR 2. Upsize to large bore tubes 3. Use drain tracts to guide access to cavities with necrosis for debridement/drainage. Can use endoscopes and ureteroscopes, ring forceps and lap instruments to remove necrotic tissue

Question 26

pancreatic psueodcyst drainage

Answer 26

1. Access peritoneal cavity via laparoscopic or open technique (bilateral subcostal versus upper midline) 2. Intraop ultrasound: identify pseudocyst, pancreas duct 3. Make an anterior gastrostomy to expose posterior wall of stomach. Cauterize posterior wall to enter into pseudocyst. Biopsy cyst wall, debride cavity 4. Make an anastomosis between cyst and posterior stomach wall >5 cm with locking PDS or Vicryl stitch. For cystojejunostomy, use a roux-en-y drainage. Can also insert an EndoGIA into the cavity to make stapled anastomosis. 5. Cholecystectomy

Question 27

total pancreatectomy (Advanced)

Answer 27

1. Upper midline or bilateral subcostal incision 2. Open lesser sac, dissect inferior border of pancreas left of SMV, preserve IMV. Dissect superior pancreas left of celiac trunk. Kocherize. 3. Retropanc tunnel, expose GDA and divide to uncover portal vein. 4. Divide bile duct 5. Splenectomy; preserve left gastric artery. 6. Transect stomach 7. Mobilize head of pancreas off of SMA/SMV and remove 8. Reconstruct (retrocolic choledochojejunostomy, gastrojejunostomy 30-40 cm from LOT) +/- transplantation 9. Feeding jejunostomy

Question 28

ampullary resection for tumor - transduodenal (advanced)

Answer 28

Transduodenal approach appropriate only for poor surgical candidates for Whipple or <6mm with negative nodes on EUS (T1). 1. Ex lap, enter lesser sac, kocherize widely. 2. Place stay sutures on antimesenteric D3 and make a 3 cm longitudinal duodenotomy. 3. Dissect the underlying neoplasm within the pancreas head and resect. 4. Reapproximate pancreas duct, CBD and duodenal mucosa with interrupted absorbable suture. 5. Stent, drain, close duodenum transversely.

Question 29

whipple/pancreaticoduodenectomy (advanced)

Answer 29

1. Dx lap 2. Open lesser sac 3. Follow middlce colic vein to SMV and create retro-pancreatic tunnel 4. Kocher - palpate SMA 5. Cholecystectomy 5. Follow/dissect common hepatic artery, taking CHA node. Ligate GDA 6. Finish superior portion of retropancreatic tunnel 7. Divide bile duct, stomach, small bowel distal to LoT, and pancreas 8. Create my pancreatico jejunostomy and choledochojejunostmy with 5-0 PDS and gastrojejunostomy with 3-0 PDS (2- layer). 9. Leave two close suctioned drains one anterior and one posteiror to the hepatic and biliary anastomoses 10. close

Question 30

chronic panreatitis management (dilated duct, no head involvement) - Peustow:

Answer 30

Peustow: lateral pancreaticojejunostomy for dilated duct with no head involvement. Enter lesser sac, lift stomach, localize duct with US, aspiration, make a lateral pancreaticojejunostomy with RNY drainage.

Question 31

chronic panreatitis management (dilated duct and head inflammation) - Frey:

Answer 31

Frey: head resection plus lateral pancreaticojejunostomy for dilated duct and head inflammation. 1 cm rim of pancreas tissue along with duodenum is left behind. Expose anterior pancreas via lesser sac, lift stomach and localize pancreas duct. Resect pancreas head with cautery and make a lateral pancreaticojejunostomy with RNY drainage.

Question 32

chronic panreatitis management (head inflammation) - Berger:

Answer 32

Berger: duodenum-preserving head resection for head inflammation. Enter lesser sac, kocherize, make a retropanc tunnel sparing the GDA and supraduodenal bile duct. Transect the pancreas neck and pull head laterally and control venous tributaries. Resect head 5mm from duodenal wall, leaving bile duct alone within the pancreas. Make a RNY anastomosis to pancreas body/tail and tack it over the pancreas bed on right.

Question 33

Lap Splenectomy

Answer 33

Laparoscopic: 1. Position L side bumped and obtain laparoscopic access/triangulate ports to LUQ 2. Systemic exploration for accessory spleens 3. Divide splenocolic and drop splenic flexure, splenorenal, lateral attachments, splenophrenic, and short gastric and gastrosplenic 4. Identify and divide SA and SV 5. Place in bag and morcellate in bag if needed

Question 34

Fundoplication (Nissen for antireflux, Toupet if dysmotility)

Answer 34

Lap Nissen 1. Position: supine, secure for trendelenberg, NG 2. Lap access - camera, two working ports, assistant port, and subxihpoid access for liver retractor 3. Expose Hiatus, reduce hernia, circumferentially incse sac if present, reduce contents below diaphragm 4. Expose right and left crus: open gastrohepatic ligament to expose R crus and develop medial plane, then expose L crus by dividing short gastric arteries 5. complete circumferential dissection of esophagus mobilizing 3cm of intra-abdominal length taking care to identify/protect vagus nerves 5. Place bougie (56Fr) and close the crura with permanent suture. Perform shoeshine maneuver to create wrap (short and floppy). Secure with permanent suture to esophagus and diaphragm to ensure 360 wrap. 270 degree wrap if dysmotility present.

Question 35

Cricopharyngeal Myotomy for Zenker Diverticulum excision (advanced)

Answer 35

If <2 cm  myotomy. If > 2cm  diverticulectomy with myotomy. 1. Place supine with shoulder roll and incise over SCM. Retract laterally to expose esophagus/pharynx. 2. Inject air into esophagus as needed to identify pouch. 3. Divide cricopharyngeus muscle. Continue incision onto inferior constructor muscle. Take incision down to mucosa. 4. Pexy or remove the pouch with a stapler over a 56 Fr bougie.

Question 36

Esophageal Perforation - repair/resection (advanced)

Answer 36

Primary Repair: debride tissue enlarge myotomy to expose entire mucosal defect Close mucosa and muscle in 2 layers with absorbable suture Create a tissue flap and lay over muscle Add a Heller and fundoplication if patient has achalasia. Intercostal Flap: Divide muscle off of the ribs medially and anteriorly as a flap and rotate down over repair. Blood supply to this comes from intercostal artery just below the rib and POSTERIOR to rib.

Question 37

Esophagectomy - cancer (advanced)

Answer 37

principles: preserve R gastroepiploic for gastric conduit, mobilize stomach, lymphadenectomy, conduit, NG, consider feeding jejunostomy Ivor-Lewis: 1. Laparotomy, mobilize stomach, lymphadenectomy, pyloromyotomy and gastric conduit/sleeve 2. R thoracotomy, anastomosis wtihin chest after esophageal mobilization and resection 3. NG tube and consider feeding jejunostomy

Question 38

Esophagomyotomy (Heller) (advanced)

Answer 38

1. Place a nasogastric tube prior to induction to prevent aspiration. Gain access with five laparoscopic port sites. 2. Dissect/expose anterior aspect of the distal esophagus from hiatus. Expose the GEJ by removing the gastroesophageal fat pad taking care to preserve the anterior vagus nerve. 3. Divide the longitudinal and the circular muscle fibers for at least 6 cm onto the esophagus and 2 cm onto the stomach. Separate the edges of the myotomy from the underlying mucosa for half of the esophageal circumference. 4. Insufflate the esophagus under water to test for a leak from the myotomy site. Perform an anterior (Dor) fundoplication.

Question 39

Stomach Cancer principles: margin, LN needed, when to perform total gastrectomy, specific considerations for ulcer operations

Answer 39

For cancer procedures, 5 cm margins and 15 lymph nodes are needed. Perform a total gastrectomy if 5 cm margin cannot be obtained with distal gastrectomy. For ulcer operations, look for h pylori and associated cancers (biopsies) and consider adding vagotomy if patient has already been on acid suppressing medication.

Question 40

Distal Gastrectomy

Answer 40

1. General anesthesia, supine position, NG decompression. Make upper vertical midline incision. 2. Kocherize the duodenum. Divide the gastrocolic ligament to enter the lesser sac. Examine the stomach and identify the region of the ulcer to determine the appropriate extent of resection. 3. Divide the greater omentum; ligate and divide the right gastroepiploic vessels near the GDA. Incise the gastrohepatic ligament, then ligate and divide the right gastric artery proximally. 4. Divide the duodenum and stomach with a stapling device. Oversew both staple lines, leaving a portion of the gastrotomy closure available for reconstruction. 5. Reestablish GI tract continuity via either Billroth I or II reconstruction. Confirm nasogastric placement.

Question 41

Partial Gastrectomy (GIST):

Answer 41

1. Obtain abdominal access (upper midline incision versus laparoscopic). Explore for metastases and resectability. 2. Perform wedge or distal gastrectomy with 1 cm margins to completely clear tumor. 3. Remove any other organs/tissue that adhere to tumor as necessary. 4. Reconstruct if wedge was not possible.

Question 42

Total Gastrectomy

Answer 42

Total Gastrectomy: 1. Obtain abdominal access and perform full exploration. 2. Mobilize GE junction and esophagus, taking a margin of diaphragmatic crura. 3. Separate the omentum and lesser sac lining en bloc from the transverse colon. 4. Divide the short gastric vessels, and skeletonize the celiac, splenic, and common hepatic arteries, taking their lymph nodes. Ligate left and right gastric and gastroepiploic arteries at their bases. 5. Divide esophagus, stomach, and jejunum Reconstruct with esophagojejunostomy and jejunojejunostomy.

Question 43

Gastric ulcer perforation repair

Answer 43

Gastric Ulcer: biopsy ulcer for cancer and H pylori. If stable, resect ulcer with antrectomy/distal gastrectomy versus total/subtotal gastrectomy versus wedge depending on ulcer location. Add a vagotomy if patient has been on acid suppression. If patient is unstable, consider a biopsy and source control with patch.  Type I (antrum near lesser curve): wedge resection or antrectomy + billroth I  Type II/III (combined gastric/duodenal): distal gastrectomy and truncal vagotomy (increased acid production)  Type IV Proximal stomach/cardia): pending location

Question 44

Duodenal ulcer perforation repair (Graham pathc)

Answer 44

1. laparoscopic access, find defect 2. secure omentum over defect; if large may need Thal patch (jejunal serosal patch); can consider pyloric exclusion/Gastrojej if very large as well 3. closed suction

Question 45

Enteral Access (Gastrostomy) - PEG

Answer 45

PEG Pull: most common endoscopic approach. 1. Insert scope into stomach and insufflate. Locate appropriate area of tube placement via palpation and transillumination. 2. Insert guidewire into stomach under visualization and grasp with a snare from the scope. 3. Pull the guidewire into the mouth and thread a gastrostomy tube over this. 4. Pull the gastrostomy out by pulling the guidewire out of the abdominal insertion site.

Question 46

Enteral Access (Gastrostomy) - Laparoscopic

Answer 46

Laparoscopic: 1. Obtain laparoscopic access, ensure orogastric tube placment 2. Select gastrostomy site on anterior gastric wall, 2/3 between LES and pylorus on greater curve. 3. Secure stomach to gastric wall with suture (T-fastener useful). 4. Pass needle and wire transabdominally into insufflated stomach at selected gastrostomy site; confirm aspiration of gastric contents. 5. Serially dilate, insert tube and secure tube to patient.

Question 47

Enteral Access (Gastrostomy) - Stamm/Open

Answer 47

Open/Stamm: 1. Upper midline incision; grasp stomach along greater curve and bring into field. 2. Select gastrotomy site and encircle with two purse string sutures. leave untied. 3. Make gastrotomy and insert gastrostomy tube. Tie down purse string sutures. 4. Deliver tube via abdominal wall incision and tack the stomach to the abdominal wall. 5. Pull tube flush with abdominal wall and tie down pexy sutures; secure tube to the patient on abdominal wall.

Question 48

Trunchal Vagotomy

Answer 48

Truncal Vagotomy 1. Retract the left hepatic lobe laterally, divide triangular ligament as needed. 2. Incise the peritoneum and dissect the esophagus circumferentially. Identify and dissect the anterior and posterior trunks of the vagus nerves. 3. Place proximal and distal clips ~2 cm apart on each trunk and then resect the intervening nerve segments. Inspect the esophagus to ensure that all portions of the vagus nerves have been divided. 4. As needed, perform a cruroplasty to prevent hiatal hernia. 5. Perform pyloromyotomy to improve gastric drainage.

Question 49

Bleeding duodenal ulcer management

Answer 49

Bleeding Duodenal Ulcer 1. Place stay suture on pylorus and open pylorus longitudinally 2. Suture ligate bleeding vessel in ulcer crater (superior, inferior, and medial/12, 3, and 6 o’clock) stitches to encompass GDA with transverse branch. 3. Biopsy for H. pylori and perform vagotomy/pyloroplasty if needed. 4. Close duodenum transversely (complete myotomy prior to closure if vagotomy was performed).

Question 50

Ligation of bleeding duodenal Ulcer

Answer 50

Bleeding Duodenal Ulcer 1. Place stay suture on pylorus and open pylorus longitudinally 2. Suture ligate bleeding vessel in ulcer crater (superior, inferior, and medial/12, 3, and 6 o’clock) stitches to encompass GDA with transverse branch. 3. Biopsy for H. pylori and perform vagotomy/pyloroplasty if needed. 4. Close duodenum transversely (complete myotomy prior to closure if vagotomy was performed).

Question 51

Sleeve gastrectomy (advanced)

Answer 51

Laparoscopic Sleeve Gastrectomy 1. Mobilize the greater curvature of the stomach and expose left crus with complete mobilization of fundus (divide short gastrics). Lyse retrogastric adhesions. 2. Evaluate hiatus and peform hernia repair as needed over a 56Fr bougie along lesser curve. 3. Perform a longitudinal gastrectomy using a linear cutting stapler starting approximately 6 cm proximal to pylorus and ending at GEJ. 4. Remove the specimen, ensure hemostasis and close.

Question 52

RYGB (advanced)

Answer 52

RNY Gastric Bypass 1. Obtain abdominal access and place ports, explore and ensure normal anatomy. 2. Create a the jejunojejunostomy: divide jejunum 50-75 cm distal to LOT and divide mesentery to allow length to bring roux to pouch. Make a side to side stapled anastomosis at 100-150 cm distal small intestine. Close the JJ mesentery defect by affixing cut mesenteric edge to adjacent roux limb mesentery. 3. Divide omentum and bring roux limb antecolic. Place a live retractor and create a 25 mL gastric pouch with serial staple firings along lesser curve. 4. Make a stapled gastrojejunostomy, ensuring no twisting of the roux limb. Pass a 32 Fr tube into the anastomosis to prevent narrowing. Perform a leak test. 5. Close Petersen’s defect with a running stitch between roux limb staple line and transverse colon mesentery.

Question 53

Postgastrectomy revisional operations (advanced)

Answer 53

 Dumping syndrome secondary to a Billroth I or II procedure  RNY  Postvagotomy diarrhea  reversed jejunal interposition x 10 cm @ 100 cm distal to LOT (rarely done, bacterial overgrowth/obstruction)  Gastroparesis  subtotal gastrectomy with BII or RNY GJ reconstruction  Afferent loop syndrome: identify the point of obstruction with appropriate management (ie, lysis if adhesions, closure of mesenteric defect, excision of redundant loop/stricture/marginal ulcer, Braun for prior BII).  Alkaline reflux  RNY with 60 cm length +/- vagotomy  Roux stasis syndrome  resection of the Roux limb and revision versus conversion to a Billroth II with Braun enteroenterostomy  Braun: Create a jejunojejunostomy (classically with a 30-cm limb away from the stomach) between the ascending and descending loop of the jejunum leading to the gastrojejunostomy

Question 54

adhesiolysis

Answer 54

Lap v open 1. Establish abdominal access 2. Address principal site of obstruction along with other major adhesions 3. Complete lysis not necessary; don’t risk injury to bowel if adhesions are not consequential. 4. Run intestine to ileocecal valve to ensure no residual obstruction or enterotomies

Question 55

Crohn's management

Answer 55

Stricture: endoscopic dilation, stricturoplasty, segmental resection +/- stoma (resect colonic strictures due to malignancy risk).  Heineke-Mikulicz: longitudinal incison closed transversely  Finney: 10-25 cm stricture, side to side anastomosis with blind pouch  Jaboulay: same as Finney but does not include diseased bowel in anastomosis  Michelassi: side to side isoperistaltic for long segment stricture >20 cm Fistula: resection Perforation/abscess: IR drainage; primary anastomosis versus resection w diversion Colonic HGD, toxic colitis: colectomy Perianal disease; minimize tissue loss; noncutting setons, small incisions. If refractory can consider proctectomy/total PTC w end ileostomy FTT: in children, consider resection

Question 56

Ileostomy

Answer 56

Brooke/end ileostomy: 1. Excise a circular opening 2-3 cm in diameter at marked location 2. Vertically incise subcutaneous fat and anterior rectus sheath; split rectus muscle and divide posterior sheath 3. Bring ileum up through opening x 4-5cm ensuring no mesenteric twisting. 4. Open the ileum distally and place sutures in 3 quadrants: full-thickness at distal opening, then seromuscular several cm proximally, then through the dermis.

Question 57

Ileostomy takedown

Answer 57

Stoma closure: side-to-side ileocolic versus end-to-end (hand-sewn) 1. Place patient in lithotomy if there is a chance of ileorectal anastomosis. 2. Enter the abdomen and lyse adhesions 3. Identify distal bowel and ensure it can be mobilized for anastomosis. 4. Take down ileostomy and create an anastomosis. 5. Close the mesenteric defect.

Question 58

Small bowel resection

Answer 58

Lap v open: 1. Establish abdominal access 2. Adhesiolysis; identify point of obstruction or resection. Inspect the intestine from the ligament of treitz to the ileocecal valve. 3. Create mesenteric windows and divide intestine; then divide the intervening mesentery, ensuring appropriate margins and mesenteric blood supply. 4. Create anastomosis without any kinking/twisting of mesentery or tension. Stapled side to side will be created by aligning antimesenteric borders of intestine, making enterotomies and inserting cutting stapler. Inspect lumen for bleeding and close common enterotomy. Exteriorize the bowel for extracorporeal anastomosis if performing laparoscopically. If bowel is unhealthy or patient has significant risk factors consider diversion/stoma. 5. Close the mesenteric defect.

Question 59

appendectomy

Answer 59

1. Establish abdominal access. If pregnant, place incision slightly cephalad to anticipated position of the appendix (point of maximal tenderness). 2. Identify the base of the appendix where taenie coli converge. If there is no appendicitis, look for terminal ileitis, Meckel’s and ovarian pathology. 3. Divide the appendiceal mesentery and then divide the appendix just at the cecum. 4. Deliver the appendix via laparoscopic bag. Place a z stitch over the appendiceal base if open.

Question 60

partial colectomy

Answer 60

Lap v open: ureteral stents, prep w abx (PEG, neomycin, erythromycin), stoma marking. Have colonoscope available and place in lithotomy for any left-sided procedure. 1. Establish abdominal access and mobilize the colon (medial to lateral or vice versa). Ensure that the ureter is left down during this mobilization. 2. For an oncologic resection, take the vascular arcade at its root: IMA for left side, ileocolic and right branch of middle colic for right; ileocolic, right and middle colic for extended right. Dissect the vessels and divide with energy device or between clips 3. Determine points of resection including 5 cm margin for cancer. Create mesenteric windows and divide the intestine. Divide the intervening mesentery (low if oncologic). 4. Mobilize the splenic flexure if needed: divide the IMV and create space in the avascular plane between the inferior border of the pancreas, colonic mesentery and posterior stomach enter lesser sac via gastrocolic ligament at midpoint and divide to spleen. Reflect stomach cephalad to expose pancreas. Create avascular mesenteric windows on either side of the left branch of the middle colic and transect this proximally (marginal and middle colic will supply the transverse colon). Divide white line of Toldt. 5. Create a temporary stoma if needed: infection, anastomotic protection, unstable patient.

Question 61

R hemicolectomy

Answer 61

Right Hemicolectomy (lap v open): 1. Abdominal access, explore and locate tattoos. 2. Lift cecum towards abdominal wall and isolate and divide ileocolic pedicle at its origin. Create a window behind the vascular pedicle to mobilize the medial mesocolon; protect duodenum and push down and away from colon. 3. Mobilize the lateral attachments along white line of Toldt. Identify and protect the ureter. Take down the hepatic flexure and divide gastrocolic ligament up to the right branch of the middle colic artery; divide this vessel. 4. Use an energy device to divide intervening mesentery at its base. Evaluate perfusion of the colon and divide the intestine with GIA staplers. 5. Create a side to side ileocolic anastomosis through an umbilical opening; use a wound protector and ensure no twisting.

Question 62

L hemicolectomy

Answer 62

Left Hemicolectomy (lap v open): 1. Abdominal access, explore and locate tattoos. 2. Mobilize the splenic flexure. Take the IMV and left branch of the middle colic artery. 3. Mobilize the lateral attachments along white line of Toldt. Identify and protect the ureter. Identify the IMA if doing an extended left (divide at origin with an energy device). 4. Use an energy device to divide intervening mesentery at its base. Evaluate perfusion of the colon and divide the intestine with GIA staplers. 5. Bring up the distal colon through the abdominal wall and insert anvil with purse string device. Create a circular stapled anastomosis transanally after sizing appropriate; ensure no twisting. Check anastomosis with leak test using colonoscope.

Question 63

Sigmoidectomy (benign)

Answer 63

Sigmoidectomy (benign): 1. Abdominal access, explore and identify diseased areas of colon. 2. Lift the sigmoid colon towards the abdominal wall. Mobilize medially and laterally taking care to protect the ureter. 3. Make a mesenteric window at junction of colon with superior rectum and divide the distal bowel at an area of healthy tissue using GIA stapler. 4. Divide the mesentery proximally until the proximal intestinal transection point is reached. Divide the intestine with GIA stapler 5. Bring up the distal colon through the abdominal wall and insert anvil with purse string device. Create a circular stapled anastomosis transanally after sizing appropriately; ensure no twisting. Check anastomosis with leak test using colonoscope and look at the doughnuts. Add a diverting ileostomy if concerned about anastomosis.

Question 64

Hartmann's

Answer 64

Hartmann’s procedure: 1. Abdominal access, exploration, irrigation. 2. Mobilize the sigmoid colon medially and laterally taking care to protect the ureter. 3. Divide the intestine at healthy areas (rectosigmoid distally) and then divide intervening mesentery. 4. Create an end colostomy and tag the rectal stump.

Question 65

LAR

Answer 65

Low Anterior Resection 1. Abdominal access, explore, identify tattoos. 2. Mobilize the sigmoid colon medially and laterally; protect the left ureter. Divide the IMA its origin. Mobilize the splenic flexure. 3. Divide the descending colon with GIA stapler above the sigmoid flexure. Use the divide sigmoid as a handle and begin circumferential total mesorectal excision; protect the ureters and hypogastric nerves. 4. Divide rectum with TA stapler ensuring a 2-5 cm margin. Prep anastomosis with sizers and insert anvil proximally with purse-string device. Make circular stapled anastomosis, ensuring no twisting and look at doughnuts. Perform a leak test with colonoscope and add a diverting ileostomy as needed.

Question 66

APR

Answer 66

Abdominoperineal Resection 1. Abdominal access, explore, identify tattoos. 2. Perform a rectal resection with circumferential total mesorectal excision (begin posterior) after dividing the proximal margin. Carry this down to the levators. 3. Move to the perineal dissection; place a Lone Star retractor and dissect circumferentially around the external sphincter into the ischiorectal fat until meeting the previous dissection. Borders of dissection are the ischial tuberosities, coccyx and perineal body. 4. Remove the specimen and close the perineal incision in layers. Create an end colostomy and close the abdomen.

Question 67

Total Colectomy

Answer 67

Total Colectomy 1. Obtain abdominal access and mobilize the left colon. Divide bowel at the pelvic brim and divide mesentery up to the splenic flexure. Protect the left ureter. Take vessels at origin if the indication is oncologic. 2. Mobilize the splenic flexure across to the right side and take down the gastrocolic ligament. Mobilize the transverse colon and divide its mesentery towards the right side. Protect the pancreas and duodenum. 3. Continue rightward, taking down the hepatic flexure and mobilizing the right colon. Divide the mesentery. 4. Divide the ileum. Create an ileorectal anastomosis or end ileostomy.

Question 68

Colostomy

Answer 68

Colostomy Creation: stoma marking preop 1. Remove a disk of skin over marked site. Divide the fascia and split the rectus muscle to accommodate two fingerbreadths. 2. Pull the intestine through with a Babcock and ensure perfusion and no twisting of mesentery. 3. Close all other incisions prior to opening the colon. Open and mature with Brooke technique and do not disrupt the marginal artery.  End: transected end is brought up and staple line removed, then bowel edges are sewn to the skin.  Loop: bring loop of colon into wound and make a transverse incision on antimesenteric wall. Fold back cut edges and mature to skin, opening both lumens. Place a red rubber or rod under the loop to prevent retraction.

Question 69

Colostomy takedown

Answer 69

Colostomy Closure 1. Make a circumferential peristomal incision in the skin and dissect down to fascia. 2. Lyse all adhesions between colon and fascia. 3. Reverse loop colostomy by freshening edges and closing transversely or create a side-side stapled anastomosis. 4. End colostomies need to have laparotomy or laparoscopy for mobilization of colon and rectal stump. Mobilize splenic flexure as needed. Create anastomosis with circular stapler or hand-sewn.

Question 70

Lateral Internal Sphinceterotomy

Answer 70

Lateral internal sphincterotomy 1. Prone jack-knife, make lateral transverse incision over the intersphincteric groove 2. Identify internal sphincter (white fibers) and external sphincter (red fibers) and divide the internal sphincter fibers 3. Close the skin

Question 71

Anorectal abscess drainage

Answer 71

Horseshoe abscess: modified Hanley procedure 1. Small incision between the tip of coccyx and anal verge. Dissect into deep postanal space. 2. Gently separate tissues of the external sphincter, drain abscess 3. Then place seton around the sphincter complex 4. Create 2 lateral counterdrainage incisions

Question 72

Anal fistulotomy

Answer 72

1. Determine depth of fistulous tract and amount of sphincter complex involved with exam 2. If < 30% of sphincter is involved or intern opening is below dentate, insert a lacrimal duct probe and divide overlying tissue to lay open the tract. If encompassing more tissue, do not do a fistulotomy. 3. Curette/debride the tract.

Question 73

Anal fistula - Endorectal mucosal advancement flap

Answer 73

Endorectal Mucosal Advancement Flap 1. Perform a fistulectomy (excise the fistula tract). 2. Mobilize a triangle-shaped mucosal flap. 3. Pull the mucosal flap down to cover the internal opening without tension. 4. Close with interrupted absorbable suture.

Question 74

Anal fistula - Ligastion of Intersphincteric fistuila tract

Answer 74

Ligation of Intersphincteric Fistula Tract 1. Incise over the intersphincteric groove and identify the intersphincteric tract. 2. Mobilize and doubly ligate the tract between sphincters close to the intern opening and divide; scrape out all granulation tissue. 3. Curette and drain the external opening 4. Reapproximate intersphincteric incision with absorbable suture.

Question 75

Hemorrhoidectomy

Answer 75

1. grasp hemorrhoidal cushion 2. excise sharply 3. close with absorbable suture; can leave open if tissue is on a lot of tension

Question 76

BAL/Bronch

Answer 76

1. Insert flexible bronchoscopy via endotracheal tube or tracheostomy 2. Advance scope to carina, examine right and left lobes 3. To take BAL sample, wedge scope into segmental orifice. Lavage and suction into Luken’s trap

Question 77

EGD

Answer 77

1. Position supine/left side down/prone (if ERCP) 2. Examine distal esophagus for erosions or erythema on the way down, as the remainder of the exam may alter the appearance of this area and make exam on the way out inaccurate 3. If GE junction is >2 cm above the pinch of the diaphragm, this indicates a hiatal hernia 4. Entering pylorus: rotate shaft of scope slightly clockwise to advance along greater curve, position of pylorus on the screen will change from the top of the screen to the center. May need to deflect scope to the right. 5. Crossing duodenal sweep: deflect scope down and to the right, then spin all of the dials up. Pull back to visualize the ampulla. 6. Retroflexion: deflect the scope all the way up to look at GE junction

Question 78

Lower GI Endoscopy

Answer 78

1. sedate with versed and fentanyl; place on monitors. Position left lateral decubitus with knees drawn up, perform external and digital rectal exam. 2. Gently introduce scope, perform loop reduction to get through a tortuous sigmoid if needed, advance to the cecum. 3. Intubate the TI by rotating the scope until the IC valve, appearing as a slit, is seen in the inferior portion of the field, then deflect the scope tip down into the slit. 4. Withdraw the scope slowly (take at least 6 minutes) while performing complete mucosal evaluation, biopsy polyps and tattoo suspicious lesions in the submucosal plane with a non-soluble material 5. Retroflex in the distal rectum to look for internal hemorrhoids.

Question 79

SLNB

Answer 79

Sentinel Lymph Node Biopsy 1. Administer technetium at least several hours preop, and give 1% isosulfan blue in OR after intubation. 2. Make an incision just below the axillary hair line and dissect through the clavipectoral fascia. 3. Search for blue channels and remove any blue nodes. Measure radioactivity and remove all nodes with counts greater 10% of the highest count. 4. Palpate and remove any suspicious nodes. 5. Close in layers.

Question 80

ALND

Answer 80

Axillary Lymph Node Dissection 1. Make a curvilinear incision 2 fingerbreadths below axillary hairline and dissect through clavipectoral fascia. 2. Remove all fibrofatty tissue intervening between borders of the axilla (levels I and II). 3. Protect neurovascular bundles: medial pectoral nerve under pec minor (retraction), thoracodorsal (anterior to latissimus), intercostobrachial, long thoracic (over serratus). 4. Close in layers and leave a drain.

Question 81

Borders of axilla

Answer 81

axillary vein (sup) serratus anterior (medial) latissimus dorsi (lateral/inferior) subscapularis/teres minor (posterior) pectoralis muscles/clavipectoral fascia (anterior).

Question 82

Breast duct excision

Answer 82

1. Localize the duct preoperatively with lacrimal duct probe or ductography. 2. If the lesion cannot be localized, perform a subareolar duct excision. Make a circumareolar incision and remove 2-3 cm of subareolar breast parenchyma. 3. If localized, excise the corresponding duct. Identify duct by expressing fluid. Insert a lacrimal duct probe. Make a circumareolar incision in the same breast quadrant as affected duct. Make a nipple skin flap and excise the duct with a margin of surrounding tissue from nipple dermis to deeper breast tissue.

Question 83

Breast excisional biopsy/partial mastectomy

Answer 83

1. Plan incision based on preop localization (wire, radioactive seed, palpable, considering potential future incisions and cosmesis. 2. Perform a sentinel lymph node biopsy as indicated prior to partial mastectomy. 3. Make incision and dissect circumferentially around it. Use localization techniques as needed if not palpable. Orient lesion with sutures. 4. Take a specimen radiograph and confirm clip retrieval. If not visualized, take additional margins and discuss specimen film with radiology. If you still cannot find it, get a post-procedure mammogram to see if clip is left in breast tissue. Need to re-excise suspicious calcifications or retained clips.

Question 84

Mastectomy - simple

Answer 84

Total Mastectomy 1. Preop technetium/blue dye injection for SNLB. 2. Make a horizonal elliptical incision encompassing prior biopsy sites and nipple-areolar complex. 3. Make skin flaps and dissect to clavicles, inframammary fold, sternum and latissimus dorsi. Amputate breast tissue from chest wall including fascia. Orient the specimen with sutures. 4. Perform SNLB via same incision. Obtain hemostasis and place a drain; close in layers versus reconstruction.

Question 85

Mastectomy - modified radical

Answer 85

Modified Radical Mastectomy 1. Make a horizonal elliptical incision encompassing prior biopsy sites and nipple-areolar complex. 2. Make skin flaps and dissect to clavicles, inframammary fold, sternum and latissimus dorsi. Amputate breast tissue from chest wall including fascia. Orient the specimen with sutures. 3. Perform ALND via same incision. Remove all fibrofatty tissue intervening between borders of the axilla (levels I and II). 4. Protect neurovascular bundles: medial pectoral nerve under pec minor (retraction), thoracodorsal (anterior to latissimus), intercostobrachial, long thoracic (over serratus). 5. Close in layers and leave a drain.

Question 86

Breast - cyst aspiration

Answer 86

Simple cyst: Identify cyst location with ultrasound and confirm it is simple cyst. Sterilize skin and infiltrate with local anesthetic. Use ultrasound guidance to place the needle into cyst and aspirate. Make additional passes as necessary to ensure complete collapse. Convert to core needle if complete collapse not achieved. Palpable mass: Identify mass on ultrasound. Sterilize skin and infiltrate with local anesthetic. Use ultrasound guidance to place the Tru-cut needle into mass take multiple tissue passes. Do not perform without imaging guidance. Stereotactic biopsy: Position patient so that lesion is as close to skin as possible. Triangulate the lesion in 3D using scout films. Prep the skin and obtain pre and post biopsy images. Perform a vacuum-assisted core biopsy with multiple passes. Place a radiopaque clip at the site. Obtain specimen radiograph to ensure that calcifications are present in the sampled tissue.

Question 87

Parathyroidectomy

Answer 87

Four Gland Exploration 1. Transverse collar incision, divide platysma, raise subplatysmal flaps, divide median raphe between the strap muscles to expose the thyroid. 2. If using nerve monitor, check vagus signal. If checking intraoperative PTH levels, draw baseline PTH. 3. Mobilize the thyroid lobe on one side to identify upper and lower parathyroid glands, taking care to preserve their blood supply/avoid devascularizing until all glands have been identified. Perform the same on the other side. 4. Can look for ectopic glands in tracheoesophageal groove, thymus, retroesophageal space, carotid sheath. 5. Resect abnormal gland and check post-removal PTH. If appropriate drop, can close the neck. If not, look for other abnormal-appearing gland in anatomic position, or keep searching for ectopic gland if the other glands appear normal.

Question 88

Total Thyroidectomy (or hemi)

Answer 88

1. Transverse collar incision, divide platysma, raise subplatysmal flaps, divide median raphe between the strap muscles to expose the thyroid. 2. Start with the affected lobe of the thyroid gland. If using nerve monitor, obtain a vagus signal. Mobilize the upper pole of the thyroid lobe, taking care to preserve the external branch of the superior laryngeal nerve. Can use nerve monitor to identify this structure (stimulating will cause contraction of the cricothyroid muscle). Also take care to preserve upper parathyroid gland. 3. Identify the course of the recurrent laryngeal nerve and the inferior parathyroid gland. Carefully mobilize the thyroid off these structures by performing a capsular dissection. 4. Once you’ve reached the trachea, either divide the isthmus (if performing a lobe) or continue to the other side (if performing a total). 5. Confirm hemostasis, confirm that both recurrent laryngeal nerves are intact and functioning and that the parathyroid glands that have been visualized are still viable, place hemostatic agents, reapproximate strap muscles and platysma, close skin.

Question 89

Adrenalectomy (advanced)

Answer 89

1. Position lateral decubitus and establish pneumoperitoneum. Ports are placed two fingerbreadths below the costal margin ipsilateral to the lesion. 2. Right side: mobilize liver and place liver retractor, dissect along the superior aspect of the adrenal with energy device to take the arteries, dissect laterally and inferiorly along Gerota’s fascia, clip and divide short adrenal vein draining directly into IVC. 3. Left side: mobilize spleen, left colon medially to expose the left adrenal, carefully dissect away from tail of pancreas, inferior dissection along Gerota’s fascia, clip and divide adrenal vein (drains into left renal vein on this side) 4. In both scenarios, posterior extent of dissection is the muscles of the retroperitoneum/diaphragm 5. Remove specimen, meticulous hemostasis

Question 90

Melanoma WLE

Answer 90

1. Elliptical incision (margin width should be 1 cm for melanomas 1 mm thick, 1 or 2 cm for melanomas 1 to 2 mm thick, and 2 cm for melanomas 2 mm thick, 5 mm for melanoma in situ) over the lesion, carry down to the level of the fascia.

Question 91

Pilonidal cystectomy

Answer 91

1. Wide excision of the pilonidal cyst and sinus down to sacral fascia, including hair removal, leave the wound open to heal by secondary intention 2. Can also close but do it off the midline 3. Gibbs procedure: core tract out from the inside

Question 92

Melanoma - SLNB

Answer 92

1. SNLB if > 0.8: inject with radioactive tracer + lymphazurin blue dye 1-2 hours preprocedure. 2. Orient incision in a way that it will be incorporated in the event of a lymph node dissection. 3. Use gamma probe to identify nodes that are 10% higher than background 4. Intraop frozen section typically not accurate and not recommended. o If primary lesion has ulceration and/or high mitotic index, but <0.8 cm depth, you should still do lymphadenectomy

Question 93

Intubation: RSI

Answer 93

1. Assess Mallampati, mouth opening, mandibular protrusion, and neck mobility (if cervical spine is cleared), call for help 2. Preoxygenation with nonrebreather—assist with jaw thrust/chin lift if needed 3. Apply cricoid pressure and induce with etomidate (0.2-0.3 mg/kg IV) and rocuronium 0.6-1.2 mg/kg IV 4. Direct laryngoscopy and advance the tube through the cords, don’t release cricoid pressure until end tidal CO2 is confirmed

Question 94

Difficult airway algorithm

Answer 94

1. If unable to intubate once, check O2 sats—if >90%, can try to intubate one more time with a Bougie. If sats <90%, have to oxygenate if able and try to place an LMA while getting set up for a cric 2. If unable to place an LMA, then cric a. Palpate thyroid cartilage and the cricoid cartilage just below it. Cricothyroid membrane is right between these. b. Immobilize the larynx with nondominant hand and palpate the cricothyroid membrane with the index finger of your nondominant hand. c. Without letting go, incised the skin vertically over the cricothyroid membrane. d. Bluntly dissect through the soft tissue down to the cricothyroid membrane and make a horizontal stab incision through the membrane e. Use finger or Bougie to dilate the tract—if placing the Bougie, will feel “tracheal clicks” to confirm you’re in the airway f. Pass the ET tube (6-mm) about 6 cm—don’t go too far! g. Remove the Bougie, inflate the ET tube cuff **Get CXR to confirm tube position

Question 95

Abd exploration for trauma

Answer 95

1. Position supine, prep very widely. 2. Swiftly and sharply enter the abdomen, evacuate hematoma, pack all four quadrants and give anesthesia a chance to catch up. 3. Sequentially remove packs and control hemorrhage. 4. Inspect the bowel for injury, inspect bilateral retroperitoneum (+/- hematoma exploration as appropriate) 5. Decide to perform damage control depending on temperature, base deficit, coagulopathy, hemodynamic instability—can do temporary abdominal closure if unstable

Question 96

Traumatic cardiac injury - repair

Answer 96

1. Place finger in the hole to temporize and ensure that anesthesia is catching up before you unleash the beast 2. Use permanent suture (Pledgeted if you have time) and place interrupted horizontal mattress sutures to close the hole 3. If the hole is near the coronaries, should throw your stitch right under the coronaries to avoid occluding/ligating them

Question 97

Fasciotomy - 4 compartment

Answer 97

Posterior compartments: medial incision made one thumb's breadth behind the tibia. The fascia overlying the soleus muscle is incised to release the superficial posterior compartments, and the muscles are freed from their attachment to the posterior tibia to release the deep posterior compartment. Anterior Compartments lateral incision is made one finger's breadth in front of the fibula. A horizontal incision is made to identify the anterior intermuscular septum. Vertical incisions are then made 1 cm anterior to septum and 1 cm posterior to the septum.

Question 98

Traumatic neck injury management

Answer 98

HARD SIGNS: shock/hypotension, active hemorrhage, expanding or pulsatile hematoma, neurologic deficit, significant subcutaneous emphysema, respiratory distress/airway compromise, air leaking out.

Question 99

Vascular embolectomy for ALI

Answer 99

Open embolectomy for ALI: 1. Longitudinal incision to expose CFA, SFA, profunda 2. Longitudinal arteriotomy, place Fogarty (traversing the distal embolus), gently inflate the balloon and pull back, retrieving thrombus 3. Always pass the catheter proximally as well to ensure you’re not missing a more proximal source of thromboembolism 4. Catheter passed at least twice—need to get at least one clean pass with the Fogarty after you’ve cleared out the thrombus 5. Arteriotomy flushed and closed with interrupted nonabsorbable suture 6. Other techniques, such as lytics, can also be performed 7. 4-compartment fasciotomy should be considered in anyone with >6 hours of ALI sx’s

Question 100

AVF - Dialysis access

Answer 100

1. Map out the course of the vasculature preop with ultrasound, prep circumferentially 2. Dissect out the artery and vein 3. Heparinize before clamping, obtain proximal and distal control 4. Make 6-mm arteriotomy 5. End-to-side radiocephalic anastomosis • Ready for access when “rule of 6’s is met” • Flow >600 ml/min • Diameter at least 6 mm • 6 mm or less below the skin

Question 101

Ladd procedure/malrotation

Answer 101

1. Supraumbilical transverse laparotomy incision 2. Eviscerate small bowel and reduce volvulus COUNTERCLOCKWISE 3. Resect any clearly necrotic bowel and leave behind whatever is marginal 4. Divide Ladd’s bands from right colon to pelvic sidewall, broaden the mesentery by opening the anterior leaflet 5. Perform appendectomy 6. Place small bowel on the right and colon on the left, leave in discontinuity/abdomen open if baby unstable

Question 102

Pyloromyotomy

Answer 102

1. NG tube right at induction, supraumbilical curvilinear incision 2. Retract omentum and transverse colon downward 3. Identify pyloric vein and incise serosa 2 mm proximal to pyloric vein 4. Start pyloromyotomy superficially and extend towards antrum, bluntly separate deep muscle fibers 5. Look for mucosal bulge and stop when you see it 6. Test for duodenal perf with insufflation test

Question 103

Meckel Diverticulectomy

Answer 103

Lap vs. open 1. Transverse laparotomy if open, identify diverticulum and divide the vessel going to the tip of the diverticulum 2. If bleeding, perform a wedge resection of the diverticulum and examine the mucosa 3. Perform a segmental resection if ischemic, there’s extensive inflammation, or the base of the diverticulum is wide, or there is an unreducible intussusception associated with it 4. Otherwise, can close this wedge resection in a Heinecke-Mikulicz fashion or just staple across the diverticulum.

Question 104

Skin Grafting

Answer 104

1. Choose appropriate type of skin graft (full thickness vs. split thickness) 2. Use a pneumatically driven dermatome to harvest the graft--can be either a sheet graft, or a meshed graft if the burn area is large 3. Affix the graft to prevent movement/shearing leading to early graft loss (can use staples, sutures, fibrin sealants) 4. Cover with a moist nonadherent dressing, followed by a bulky absorbent dressing. If the graft crosses a joint, need to splint the joint to immobilize for ~48 hours

Question 105

Salpingooophroectomy

Answer 105

Salphingoophorectomy (lap or open) 1. Develop pararectal space to allow for identification of important retroperitoneal structures 2. Incise peritoneum 1 cm lateral to the infundibulopelvic ligament parallel to the line from the round ligament to the white line of Toldt 3. Identify external iliac artery and vein. Blunt dissection of the loose areolar tissue medial to these vessels and follow this down to the sacrum to open the pararectal space 4. Identify ureter as it courses along the medial peritoneal reflection—crosses over external iliacs near the bifurcation 5. Make a window between the ureter and ovarian vessel, suture ligate or Ligasure the vessels 6. Skeletonize the peritoneum of the pelvic sidewall toward the utero-ovarian ligament, transect utero-ovarian ligament close to the uterus

Question 106

APR

Answer 106

Do with PRS for flap coverage Mark stoma pre-op Lap medial to lateral mobilization of rectosigmoid jxn and descending colon Identify L ureter Ligate superior rectal artery Divide colon at rectosigmoid jxn Dissect rectum following principles of TME ensuring to preserving the hypogastric nerves When at pelvic floor = swap to perineal dissection Wide margins; note where tumor was preoperatively Perform disseciton circumferentially, divide anococcygeal ligament posteriorly until meet up with abd dissection Remove specimen Create aperture for end sigmoid colostomy PRS flap coverage Once complete and incisions closed - mature end colostomy