Operations

Question 1

Hiatal hernia, paraesophageal hernia, and fundoplication

Answer 1

1. Position supine with lithotomy or split leg
2. Access abdomen, liver retractor
3. Incise gastrohepatic ligament
4. Expose right crus
5. Mobilize esophagus circumferentially and place penrose
6. Mediastinal mobilization to get 3cm intraabdominal esophagus (may need Collis gastroplasty)
7. Reapproximate crus with mattress nonabsorbable suture
   , (sometimes need mesh)
8. Fundoplication (if Nissen take down short gastrics) and buttress anteriorly with nonabsorbable suture for 2cm
9. PEH: ensure that you have completely brought all the contents down into abdomen, and resect sac. If injury esophagus: repair in 2 layers, leave drain, buttress with fundoplication. If pleural injury: either repair or evacuate air with red rubber cather

Question 2

Lichtenstein inguinal hernia repair

Answer 2

1. Curvilinear incision above inguinal ligament, down to external oblique
2. Incise external oblique, preserve ilioinguinal nerve, clear off shelving edge down to pubic tubercle
3. Get around sac and cord contents at pubic tubercle and place penrose
4. Dissect the sac off the cord (sac is anteromedial) down to internal ring and reduce sac into abdomen; protect cord structures
5. Place mesh at Cooper’s ligament and suture along inguinal shelf and then superiorly to conjoined; suture tails together for new internal ring
6. Close external oblique for new external ring
7. Close scarpas and skin

Question 3

McVay repair

Answer 3

Incise inguinal floor to convert possibility of femoral hernia into a direct hernia

Interrupted silk sutures to approximate conjoined tendon starting medially to Cooper’s, and down to lacunar ligament to close femoral canal, and then with transition stitch to approximate Cooper’s to inguinal ligament and then up along inguinal ligament

Question 4

Low anterior resection (or left colon or sigmoid)

Answer 4

1. Lithotomy for prep of abdomen and perineum
2. Trendelenburg
3. Mobilize colon along white line of Toldt, care to identify ureter
4. Splenic flexure mobilization so that left colon reaches pelvis
5. Score sigmoid mesentery on medial side from sigmoid down to rectum, along superior rectal artery
6. Divide pedicle to sigmoid colon
7. Elevate rectum to identify areolar plane posteriorly
8. Use energy device to free rectum circumferentially, staying in a plane close to rectum
9. Last is anterior dissection (as holds rectum in place)
10. Dissect 2cm past tumor and confirm with endoscopy
11. Articulating staple to divide rectum distally, and linear stapler to divide colon proximally, pass the specimen
12. EEA anastomosis through rectum and do leak test

Question 5

Left adrenalectomy

Answer 5

If pheo: let anesthesia know before taking vein
If malignant: en bloc with anything stuck

1. Take down lateral attachements of spleen to mobilize spleen medially and take down pancreas
2. Identify inferior phrenics (trace down on top of adrenal)
3. Identify and control left adrenal vein going into renal vein. Use ligature to separate adrenal from surrounding retroperitoneal attachements.

Question 6

Right adrenalectomy

Answer 6

1. Right supine position with bump under right side
2. Mobilize hepatic flexure of colon and right triangular ligament of liver to point of inferior phrenics. Trace inferior phrenics down to adrenal.
3. Identify adrenal veins entering IVC
4. Use ligature to separate gerota’s and surrounding retroperitoneal attachments

Question 7

Trauma neck dissection

Answer 7

1. Supine, arms out, prep neck to knees
2. SCM incision, incise platysma, retract SCM laterally
3. Identify IJ. Divide facial vein. Open carotid sheath and deal with any vascular injuries.
4. Identify esophagus (with NG tube)
5. Identify trachea
6. Leave drain

If esophagus or tracheal injury to one side, likely to have injury to the other side.
Buttress epair with strap muscle.

Question 8

Thyroidectomy and parathyroidectomy

Answer 8

1. Supine, bump under shoulder, arms tucked
2. Collar incision
3. Superior and inferior subplatysmal flaps
4. Bluntly separate straps, place retractor

Thyroid: Starting at superior pole, bluntly separate avascular plan, identify superior pole vessels and divide close to thyroid gland using harmonic or bipolar. Rotate gland anteriorly. Identify RLN in tracheoesophageal groove and protect throughout. Divide ligament of berry and separate thyroid from larynx and trachea. Do the other side in same way. Identify parathyroid glands, and reimplant any if damaged.

Parathyroidectomy: Blunt dissection medial to carotid and superior. Identify superior pole vessels. Ligate middle thyroid vein to help visualize. Identify all glands and resect as needed, sending for frozen to confirm its parathyroid, check levels. Leave small drain, close in layers, admit to obs.