Operations

Question 1

Surgical management of duodenal perforation?

Answer 1

Midline laparotomy. Close with absorbable interrupted suture if possible, then place overlay omental patch to cover defect. Large volume washout, place drain and close.

Question 2

Is histology generally required for perforated duodenal ulcers? Do they need resecting at time of surgery? What other piece of non-surgical management is required?

Answer 2

Not necessarily as rarely malignant Test for H Pylori to guide if eradication needed

Question 3

Surgical management of bleeding gastric ulcer?

Answer 3

If not controlled endoscopically - laparotomy. If distal site of ulcer, consider distal gastrectomy and reconstruction. If unsure or more proximal, consider gastrotomy and underrun + biopsy (because only other resectional options are wedge excision which is difficult to close, and total gastrectomy is much more signifcant operation.

Question 4

Surgical management of perforated gastric ulcer?

Answer 4

Laparotomy. Excise for histology, close with absorbable interrupted sutures then overlay omental patch. If extensive ulcer, resect (distal gastrectomy if distal)

Question 5

Surgical management of bleeding posteriorly sited duodenal ulcer?

Answer 5

Laparotomy. Open duodenum longitudinally (vertical duodenotomy). Usually brisk bleeding from posteriorly sited ulcer penetrating through gastroduodenal artery. Apply digital pressure to site and then use large sutures to under run superior and inferior aspect of ulcer, taking deep bites to control bleeding vessel. Once controlled close the anterior duodenotomy in 2 layers transversely to minimise stenotic complications

Question 6

Why don’t anteriorly perforated duodenal ulcers usually cause large volume UGI bleeds vs posterior?

Answer 6

Anteriors usually perforate intraperitoneally if D1, vs posterior which erode through gastroduodenal artery posteriorly.

Question 7

What vessel is usually implicated in posterior duodenal ulcer bleeds?

Answer 7

Gastroduodenal artery

Question 8

Which operation is required for HNPCC-associated colorectal cancer?

Answer 8

Panproctocolectomy

Question 9

Operation of choice for right colon cancer?

Answer 9

Right hemicolectomy with ileocolic anastomosis

Question 10

Operation of choice for transverse colon cancer?

Answer 10

Extended right hemicolectomy with ileocolic anastomosis

Question 11

Operation of choice for splenic flexure cancer?

Answer 11

Extended right hemicolectomy with ileocolic anastomosis, or left hemicolectomy with colo-colonic anastomosis

Question 12

Why is right hemicolectomy with ileocolic anastomosis usually preferred to left hemicolectomy with colo-colonic anastomosis for splenic flexure cancer?

Answer 12

Less risk of anastomotic leak with ileocolic anastomosis

Question 13

Operation of choice for left colonic cancer?

Answer 13

Left hemicolectomy with colo-colonic anastomosis

Question 14

Operation of choice for sigmoid colon cancer?

Answer 14

High anterior resection with colo-rectal anastomosis

Question 15

Operation of choice for cancer of upper rectum?

Answer 15

Anterior resection with total mesorectal excision, colo-rectal anastomosis

Question 16

What is total mesorectal excision?

Answer 16

Removal of mesorectal fat and lymph nodes

Question 17

Operation of choice for cancer of lower rectum?

Answer 17

Anterior resection with low total mesorectal excision, colo-rectal anastomosis +/- defunctioning stoma

Question 18

Operation of choice for cancer of anal verge?

Answer 18

APER - abdomino-peroneal excision of colon and rectum with no anastomosis possible.

Question 19

What is a Hartmann’s procedure? Can it be reversed?

Answer 19

Rectosigmoid resection (high anterior resection) with formation of end colostomy and closure of Hartmann’s pouch, which is left in abdomen. Can be reversed via direct anastomosis or with loop ileostomy formation, which will later be closed separately.

Question 20

Why may Hartmann’s procedure be done for e.g. perforated sigmoid cancer?

Answer 20

Risk of anastomotic leak is significantly higher in bowel perforation, especially for colo-colic anastomosis, so high anterior resection and end colostomy formed.

Question 21

Operation of choice for obstructing rectal cancer? Why?

Answer 21

Defunctioning loop colostomy - as high risk of anastomotic leak, surgery harder and danger of positive resection margin in unstaged patient.

Question 22

How does management of obstructing colonic cancers differ to that of obstructing rectal lesions?

Answer 22

For colonic, options are stenting vs resection - rarely defunctioned For rectal, have to defunction with loop colostomy

Question 23

What is the definitive surgical management for UC? Why might this not be done acutely and what would be done instead?

Answer 23

Panproctocolectomy including removal of rectum, +/- formation of ileoanal J pouch. May not be done in emergency settings due to risk of removal of rectum - may have subtotal colectomy and later proctectomy.

Question 24

What restorative options are there following subtotal colectomy for UC?

Answer 24

Completion proctectomy and formation of ileoanal J pouch (or keeping end ileostomy).

Question 25

Surgical option of choice for acutely unwell colitic not responding to medical therapy?

Answer 25

Subtotal colectomy and end ileostomy

Question 26

Procedure for debriding an open fracture?

Answer 26

Under GA Debride non-viable skin and wound edges as minimum Assess underlying muscle for viability and remove non-viable fat and muscle Remove foreign material and bony fragments Thorough irrigation - at least 6 litres saline Stabilise fracture with ex-fix Usually don't close wound primarily unless small, uncontaminated type 1 wound - wait for re-look and closure with plastics

Question 27

Outline procedure for DHS?

Answer 27

Regional or GA depending on patient factors Position on fracture table using II to reduce fracture prior to skin incision Prep and drape Incise over greater trochanter Dissect down to greater trochanter Insert guide wire up into femoral head under II Exchange guidewire for cannulated compression screw to approximate displaced fragments Attach screw to plate running along lateral aspect of upper femur Screw plate to femur to hold reduction Close wound in layers +/- drain

Question 28

What fracture are DHS suitable for?

Answer 28

Outside of joint capsule - extracapsular pertrochanteric (intertrochanteric). Sometimes suitable for elderly undisplaced intracapsular (valgus impacted subcapital) fractures but risk of AVN so usually go for arthroplasty anyway. Reverse oblique or subtrochanteric may need IM nail

Question 29

What procedure is ideal for head of pancreas cancer if operable?

Answer 29

Whipple's - newer techniques such as pylorus preserving and SMA/SMV resection

Question 30

What is a Whipple's procedure? What is taken and what is the result?

Answer 30

For head of pancreas carcinoma - pancreaticoduodenectomy, also takes gallbladder. Left with choledochojejunostomy, pancreaticojejunostomy and gastrojejunostomy

Question 31

Potential surgical option for carcinoma of body/tail of pancreas?

Answer 31

Distal pancreatectomy

Question 32

What 4 factors affect decision on restoring continuity folllowing colorectal resection?

Answer 32

Perforation vs no perforation Vascular supply Mucosal apposition Tissue tension

Question 33

Options for obstructing colonic lesions?

Answer 33

Stent vs primary resection Rarely defunction

Question 34

What operation is required for sphincter involvement or very low rectal tumours?

Answer 34

APER

Question 35

What clearance margin is required in rectum?

Answer 35

2cm distal margin

Question 36

What patients would you offer neoadjuvant radiotherapy to in rectal cancer?

Answer 36

Higher grade - T1, 2 and 3 /N0 don't need and can go straight for surgery

Question 37

How do you manage potentially resectable pancreatic head cancer with obstructive jaundice? What do you avoid?

Answer 37

ERCP and plastic stent Avoid metallic stents as these compromise resectability

Question 38

Benefits/risks of total hip replacement over hemiarthroplasty?

Answer 38

Better function and prosthetic survivorship But higher risk of dislocation

Question 39

Outline surgical management of extracapsular hip fractures?

Answer 39

Question 40

What is most important factor in managing young patients with femoral neck fractures?

Answer 40

Retaining femoral head - significant sequalae over time with THRs in young (wear, dislocation, revision) So even displaced intracapsular fractures generally internally fixed despite risks of AVN and non-union but discuss with patient

Question 41

Outline surgical management options for intracapsular neck of femur fractures?

Answer 41

Question 43

How would you manage SBO secondary to long termineal ileal strictures in Crohns? How would this differ to short segment strictures?

Answer 43

Ileocaecal resection For shorter segments use stricuroplasty

Question 44

What does the bowel look like in acute Crohns laparotomy? What does the mesentery feel like?

Answer 44

Externally inflamed bowel with thick wall that may feel fibrotic Mesentery is friable and fatty

Question 45

What surgical options would be preferable for Crohn's? What do you not do?

Answer 45

Avoid segmental resection Prefer subtotal colectomy, panproctocolectomy, staged subtotal colectomy and proctectomy Don't bother with restorative procedures as can get inflammation of these e.g. ileoanal pouch

Question 46

What layers do you go through in open appendicectomy?

Answer 46

Skin Subcutaenous tissue Campers then Scarpa's fascia External oblique (?) aponeurosis Internal oblique muscle Transversalis muscle Transversalis fascia Peritoneum

Question 47

Outline how to perform open appendicectomy?

Answer 47

Consent, GA, WHO checklist, prep + drape, supine etc, antibiotics Transverse incision over McBurney's point = Lanz - 1/3 from ASIS to umbilicus on right side Deepen incison down in line of fibres and open peritoneum between clips Explore RIF and identify appendix, send pus if any there Ligate mesoappendix incl base of appendicular artery and then base of appendix Submit appendix for histology Suction free fluid, washout only if contamination Run small bowel for co-incidental pathology e.g. Meckel's Close in layers

Question 48

Describe how to do laparoscopic appendicectomy? Specific things to consider?

Answer 48

Consent, GA, supine, prep + drape, WHO checklist, Abx, specifically consider catheter to deflate bladder and reduce risk of iatrogenic injury w trochar (+improve pelvic access in females) Open Hassan technique to insert port site at umbilicus - infra-umbilical cut down to insert 10mm port with blunt ended tip under direct vision Air insufflation (10-12mmHg) and insert camera - 10mm 30 degree laparoscope Insert 2-3 further ports in suprapubic (5mm) and LIF (5 or 10mm) region under direct visualisation Localise appendix, dissect mesappendix away and ligate base and vessels with loops Remove with bag and send for histology Run rest of bowel for Meckels, pelvic region in females Suction free fluid, washout if contaminated only Remove port sites under direct visualisation and close

Question 49

How would you approach an incorrect swab count at the end of surgery?

Answer 49

Stop, don't wake patient Recheck swab count and examine operative field/surrounding drapes If still not found, call senior but consider re-opening wound and re-exploring operative site If still unable consider II to localise as surgical swabs have radio-opaque markers to identify on XR

Question 50

What would you do if on operation you found a normal appendix but no other pathology to account for presentation?

Answer 50

Usually take anyway - sometimes histological evidence of early inflammation

Question 51

What would you do if on operation you found a normal appendix but alternative pathology e.g. Meckels?

Answer 51

Leave appendix and treat pathology if satisfied it would account for symptoms

Question 52

How might you close a regular open appendicectomy at the skin vs a heavily contaminated one?

Answer 52

Regular - absorbable subcuticular stich If heavily contaminated consider interrupted sutures or clips

Question 53

Why are tourniquets used in surgery?

Answer 53

Minimise blood loss, improve clarity of operative field

Question 54

How are tourniquets applied and used in surgery? Key safety points?

Answer 54

Apply to distal extremity remote to op site Ensure limb padded, machine checked and facilitates pressure monitoring Ensure when prepping skin that prep doesn't run under tourniquet Inflate only after prophylactic Abx given Pressure - usually 100mmHg above systeolic

Question 55

Roughly how long would you keep tourniquet up for in a well adult for surgery?

Answer 55

Max 2 hours

Question 56

Post-inflation systemic affects of applying tourniquet?

Answer 56

Increased SVR, CVP and BP BP gradual increases over time Induced hypercoagulable state (vascular disruption) Slow increase in core temp

Question 57

Post deflation systemic effects of tourniqet use in surgery?

Answer 57

Fall in CVP, BP and SVR Increase end tidal CO2 Increased fibrinolysis Fall in core temp Rise in potassium and lactate, reperfusion injury at worst

Question 58

4 absolute contraindications to tourniquet use in surgery?

Answer 58

Severe PVD Previous vascular surgery on site Fracture/thrombosis at site of application AV fistula in same limb

Question 59

5 relative contraindications to tourniquet use in surgery?

Answer 59

Infection at site Sickle cell disease PMH of VTE Skin grafts at site Lymphoedema in same limb

Question 60

6 complications of tourniquet use in surgery?

Answer 60

Skin injury either from incorrect application or burns if prep accumulates underneath Damage to muscle at site or distally Damage to underlying vessels In those with PVD - plaque rupture, dislodgement and embolization Damage to nerves - at site (neurapraxia) and distally due to ischaemia

Question 62

Describe this appearance? What are the issues with it and why may this have happened?

Answer 62

Midline scar which appears to be poorly healed, possibly due to dehiscence and regular redressing Right iliac fossa stoma - spouted so likely ileostomy - with surrounding skin marks from stoma appliance

Question 63

What kind of GI anastomosis is most likely to heal without complications? What areas are at highest risk?

Answer 63

Small bowel best Oesophagus and rectum highest risk

Question 64

Systemic factors increasing risk of anastomotic breakdown?

Answer 64

Sepsis,infection Haemodynamic instability Jaundice Diabetes Poor nutrition Steroids Heavy local contamination, poor surgical technique

Question 65

Describe how to do a primary small bowel anastomosis? e.g. following segmental small bowel resection

Answer 65

Drape operative site to prevent local soiling Apply soft non-crushing bowel clamps to bowel 10cm upstream of resected ends Meticulous haemostasis 2 stay sutures at mesenteric and antimesenteric borders of bowel with 3/0 round bodied PDS Confirm orientation and place interupted 3/0 sutures at 5mm intervals along bowel- seromuscular sutures with knots lying externally, then invert mucosa Once all sutures secured, tie or remove stay sutures and close small mesenteric defects prior to returning bowel

Question 66

4 principles of performing vascular anastamoses?

Answer 66

Use non-absorbable monofilament e.g. prolene Round bodied needle Choose correct size for anastomosis Continuous suture from inside to outside of artery to avoid raising intimal flap

Question 67

Indications for elective splenectomy?

Answer 67

Haematological conditions e.g. haemolytic anaemias, hereditary ellipto/spherocytosis Malignancy e.g. lymphoma Cysts/abscesses

Question 68

How would you perform an elective, open splenectomy?

Answer 68

Pre-op liaison with haematologists, ensure pneumo and meningococcal vaccines given (more effective with functioning spleen) Consent, WHO, supine, GA etc. NG tube insertion to decompress stomach Midline/left subcostal incision Mobilise spleen with hilar control if very large Divide and ligate short gastric vessels, which are in gastrosplenic ligament Mobilise the colonic splenic flexiure Idnetify hilum and securely ligate vascular pedicles individually, ensuring not to damage pancreatic tail (which is also in lienorenal ligament) Divded lienorenal ligaments and remove spleen If spleen small - can fully mobilise and divide vascular pedicle at end Haemostase, non-suction drain in bed Close in layers

Question 69

Describe how to perform emergency splenectomy? Why is this different from elective?

Answer 69

Haemodynamic control invariably present as this is often indication for splenectomy Laparotomy Pack all 4 quadrants and then allow anaesthetics to control haemodynamics Carefully remove packs and examine quadrants for collateral injuries Put in self-retaining retractor e.g. Balfour to access LUQ Remove LUQ pack and inspect spleen Bring spleen to wound and control hilar vessels - if difficult place atraumatic clamp across hilum taking care not to get pancreatic tail Once hilum secure, divide short gastric vessels and remove spleen by dividing remaining attachments If splenic remnants - can implant fragment into omentum Washout, haemostase, insert NG tube and drain Close in layers

Question 70

4 changes seen post splenectomy?

Answer 70

Platelets rise first Howell Jolly bodies appear over following weeks Target cells, Pappenheimer bodies Risk of sepsis to encapsulated organisms

Question 71

When is it best to give platelets in splenectomy surgery for ITP

Answer 71

After splenic artery clamped